Lyrica (Pregabalin) Prior Authorization Form

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LYRICA (pregabalin)
PRIOR AUTHORIZATION FORM
Please complete and fax all requested information below including any progress notes, laboratory test results, or
SM
chart documentation as applicable to Gateway Health
Pharmacy Services. FAX: (888) 245-2049
If needed, you may call to speak to a Pharmacy Services Representative.
PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm
PROVIDER INFORMATION
Requesting Physician:
NPI:
Physician Specialty:
Office Contact:
Office Address:
Office Phone:
Office Fax:
MEMBER INFORMATION
Patient Name:
Gateway ID:
DOB:
DRUG INFORMATION
Strength & Frequency:
Duration:
Is the patient currently receiving requested medication?
Yes
No
Date Medication Initiated:
MEDICAL HISTORY (Attach supporting clinical information with this form)
Diagnosis
Fibromyalgia
Neuropathic pain associated with diabetic peripheral neuropathy
 Is the member currently receiving treatment for diabetes with an antidiabetic agent?
Yes
No
Partial onset seizure disorder
 Is Lyrica being used as adjunctive therapy?
Yes
No
If yes, please list other medication(s):
Neuropathic pain associated with spinal cord injury
Postherpetic neuralgia
Other (please specify):
PREVIOUS MEDICATIONS USED TO TREAT THE ABOVE DIAGNOSIS
Drug Name
Strength/Frequency
Dates of Therapy
Status (Discontinued & Why or Current)
REAUTHORIZATION
Has treatment with Lyrica provided improvement in the member’s condition?
Yes
No
Please describe response:
ADDITIONAL SUPPORTING INFORMATION or CLINICAL RATIONALE
Prescribing Physician Signature
Date
Revised 6/2017

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