Form Gr-69176 - Lyrica (Pregabalin) Prior Authorization Request

2017 Lyrica

(pregabalin) prior authorization request

Page 1 of 2

(You must complete both pages.)

Coverage Criteria for New Starts:

•

Partial seizure disorder for members with previous trial/failure or contraindication to gabapentin OR

•

Fibromyalgia for members with previous trial/failure or contraindication to generic Cymbalta (duloxetine) OR

•

Diabetic peripheral neuropathy for members with previous trial/failure or contraindication to generic Cymbalta (duloxetine) OR

•

Post-herpetic neuralgia for members with previous trial/failure or contraindication to gabapentin OR

•

Neuropathic pain associated with spinal cord injury.

Authorization Period: Remainder of contract year.

Please fax completed form to: 1-800-639-9158

For urgent requests, please call: 1-800-551-2694

Patient information

Prescriber information

Patient name

Today’s date

Physician specialty

Patient insurance ID number

Physician name

NPI/DEA number

Patient address, city, state, ZIP

Physician address, city, state, ZIP

Patient home telephone number

M.D. office telephone number

Gender

Patient date of birth

M.D. office fax number

Male

Female

Diagnosis and medical information

Medication requested

Strength and route of administration

Frequency

New prescription OR date therapy initiated

Quantity

Day supply

Expected length of therapy

Diagnosis (Please check all boxes that apply and include all office notes supporting diagnosis.)

Partial Seizure Disorder

Fibromyalgia

Diabetic peripheral neuropathy

Post herpetic neuralgia

Neuropathic pain associated with spinal cord injury

Other diagnosis/(ICD 10):

___________________________________________

Please check all boxes that apply:

Patient is stable on current drug(s) and/or current quantity, and therapy change would likely result in adverse clinical outcome.

All covered Part D drugs on any tier of the plan’s formulary would not be as effective for the enrollee as the requested formulary drug

and/or would likely have adverse effects for the enrollee.

For the diagnosis of partial seizure disorder or post-herpetic neuralgia, gabapentin (Neurontin ) would likely not be as effective as

Lyrica or likely to cause the member adverse effects therefore the member needs an exception to the requirements for Lyrica .

For the diagnosis of fibromyalgia or diabetic peripheral neuropathy, duloxetine (Cymbalta ) would likely not be as effective as

Lyrica or likely to cause the member adverse effects therefore the member needs an exception to the requirements for Lyrica .

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error, please notify us immediately by telephone at 1-800-551-2694.

GR-69176 (11-16) 2017