Pregabalin (Lyrica, Lyrica CR) (PDF)
Defines medical necessity criteria, initial and continued authorization, dosing limits, covered indications (FDA and selected off-label), exclusions, and approval durations for pregabalin immediate-release and controlled-release across Commercial, HIM, and Medicaid lines of business.
2Q 2025 annual review: for neuropathic pain associated with treatment of cancer, revised maximum dosage from 300 mg/day to 600 mg/day per NCCN; references reviewed and updated; added off-label criteria for RLS; added step therapy bypass for IL HIM per IL HB 5395.
Per September SDC, added clarification that for Commercial and HIM, requests for immediate-release pregabalin should be reviewed using step therapy criteria CP.CPA.83 and HIM.PA.109.
2Q 2024 annual review: for partial onset seizures, revised 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; added GAD products and dosing to Appendix B.
Multiple earlier annual reviews noted 'no significant changes' besides template and wording clarifications and brand-to-generic redirection language.
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