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

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Yes

Does the patient require higher dosage (quantity limit exception)?

►If yes, indicate quantity requested:

per 30 days OR quantity

per day

The number of doses available under the dose restriction for the prescription drug has been ineffective in the treatment of the

enrollee’s disease or medical condition.

The number of doses available under the dose restriction for the prescription drug, based on both sound clinical evidence and

medical and scientific evidence, the known relevant physical or mental characteristics of the enrollee, and known characteristics of

the drug regimen, is likely to be ineffective or adversely affect the drug’s effectiveness or patient compliance.

Please list all medications the patient has tried specific to the diagnosis and specify below.

CURRENT/PAST MEDICATIONS USED

DATES OF TREATMENT

THERAPEUTIC OUTCOME

Other supporting information

*NOTE: All exception requests require prescriber supporting statements. Additionally, requests that are subject to prior authorization (or

any other utilization management requirement), may require supporting information. Please attach supporting information, as necessary,

for your request.

I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true,

and that documentation supporting this information is available for review if requested by the health plan sponsor, or, if applicable, a state or

federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is

material to a claim ultimately paid by the United States government or any state government may be subject to civil penalties and treble

damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733. By signing this form, I represent that I have

obtained patient consent as required under applicable state and federal law, including but not limited to the Health Information Portability and

Accountability Act (HIPAA) and state re-disclosure laws related to HIV/AIDS.

Prescriber signature

Date

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GR-69176 (11-16) 2017