Pregabalin (Lyrica, Lyrica CR)
Clinical coverage and medical necessity criteria for pregabalin (immediate-release and controlled-release) across Commercial, HIM/ICHRA, Medicaid, and ICHRA lines of business, including initial and continued approval criteria, dosing limits, excluded indications, and billing/authorization durations.
Added ICHRA line of business.
Added step therapy bypass for Illinois HIM per IL HB 5395.
For neuropathic pain associated with treatment of cancer, revised maximum dosage from 300 mg/day to 600 mg/day per NCCN.
Added off-label criteria for restless leg syndrome (RLS) with dosing limits.
For partial onset seizures, revised pediatric maximum dose from 420 mg to 14 mg/kg/day for members < 30 kg per PI.
Clarified usage of pregabalin immediate release only for neuropathic pain associated with spinal cord injury per PI.
Per September SDC, for Commercial and HIM requests immediate-release pregabalin should be reviewed using step therapy CP.CPA.83 or HIM.PA.109 unless formulary requires prior authorization.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.