CurrentCignaPolicy N/A

Neurology - Lyrica CR Prior Authorization with Step Therapy Policy

Defines prior authorization and step therapy requirements for pregabalin extended-release (Lyrica CR and generics) for prescription benefit plans administered by Cigna companies; applies to providers requesting coverage for these products.

Policy Summary

PayerCigna

PolicyNeurology - Lyrica CR Prior Authorization with Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial — step therapy update

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document a trial of gabapentin IR or pregabalin IR; if brand Lyrica CR is requested and generic ER has not been tried, authorize generic pregabalin ER when criteria are met.

SourceLink

POLICY UPDATE CHANGES

If the patient is requesting brand Lyrica CR and meets the standard Neurology - Lyrica CR PA Policy criteria AND has tried immediate-release gabapentin or immediate-release pregabalin BUT has not tried generic pregabalin extended-release tablets, an approval for generic pregabalin extended-release tablets will be authorized.

1 yearapproval duration

Apr 29, 2026last review

>3 monthsPHN definition

Coverage Criteria for Pregabalin Extended-Release (Lyrica CR and Generics)

Policy Summary

PayerCigna

PolicyNeurology - Lyrica CR Prior Authorization with Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial — step therapy update

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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.

Neuropathic pain associated with diabetic peripheral neuropathy: Patient has tried gabapentin immediate-release (brand [Neurontin] or generic) or generic immediate-release pregabalin.trial of IR product

Approve for 1 year when criteria A and B are met

If brand Lyrica CR is requested (DPN): Patient has tried generic pregabalin extended-release tablets AND cannot continue to use the generic because, per the prescriber, a formulation difference in inactive ingredient(s) (e.g., dyes, fillers, preservatives) would cause a significant allergy or serious adverse reaction.trial of generic ER and documented inability to use generic due to inactive ingredient(s)

Both i and ii required

Postherpetic neuralgia (PHN): Patient has tried gabapentin immediate-release (brand [Neurontin] or generic) or generic immediate-release pregabalin.trial of IR product

Approve for 1 year when criteria A and B are met

If brand Lyrica CR is requested (PHN): Patient has tried generic pregabalin extended-release tablets AND cannot continue to use the generic because, per the prescriber, a formulation difference in inactive ingredient(s) (e.g., dyes, fillers, preservatives) would result in a significant allergy or serious adverse reaction.trial of generic ER and documented inability to use generic due to inactive ingredient(s)

Both i and ii required

Provider Requirements, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for pregabalin extended‑release tablets. When criteria are met, approvals are granted for 1 year.

Approval duration: 1 year when policy criteria are met.

Step Therapy

Step Therapy Requirement

Step therapy requires a trial of gabapentin immediate‑release (brand Neurontin or generic) or generic immediate‑release pregabalin AND trial of generic pregabalin extended‑release (Step 1) prior to coverage of brand Lyrica CR (Step 2). If a patient requests brand Lyrica CR but has tried immediate‑release gabapentin or immediate‑release pregabalin and has not tried generic pregabalin extended‑release, an approval for the generic pregabalin extended‑release will be authorized. The step therapy requirement applies to FDA‑approved indications listed in the policy.

Step 1: Trial of gabapentin immediate‑release (brand or generic) OR generic immediate‑release pregabalin, AND trial of generic pregabalin extended‑release tablets.
Step 2: Brand Lyrica CR (pregabalin ER) requires meeting Step 1 or documented inability to use generic due to inactive‑ingredient formulation differences causing significant allergy/serious adverse reaction.

Denial Risk

Submission, Review, and Denial for Unsupported Billing

Providers must submit prior authorization and coverage requests consistent with the member's applicable benefit plan document and include supporting clinical information. Requests will be reviewed against the terms of the benefit plan and the clinical criteria in this policy. Claims submitted for services or drugs billed without covered diagnosis or procedure codes under the applicable coverage policy will be denied as not covered.

Submit requests with relevant clinical documentation and applicable covered diagnosis/procedure codes.
Claims lacking covered codes under the policy will be denied as not covered.

Key Definitions

Postherpetic neuralgia (PHN) — definition and context

DefinitionPersistence of pain greater than 3 months after resolution of the herpes zoster rash.

Clinical contextPHN is a neuropathic pain indication for which pregabalin extended‑release tablets are approved in adults.

Exclusion noteEfficacy of pregabalin extended‑release tablets has not been established for fibromyalgia or as adjunctive therapy for partial onset seizures.

Related agentsGabapentin IR and pregabalin IR also have PHN listed among their indications in prescribing information.

Background

Pregabalin extended-release (Lyrica CR and approved generics) is indicated by this policy for the FDA-approved neuropathic pain indications—diabetic peripheral neuropathy (DPN) and postherpetic neuralgia (PHN)—when the coverage criteria are met. Prior authorization is recommended and approvals are issued for 1 year when criteria are satisfied. The policy also establishes step therapy: a trial of gabapentin immediate-release (brand or generic) or generic immediate-release pregabalin is required before brand Lyrica CR, and if brand is requested but the member has not tried generic pregabalin extended-release, an approval for the generic extended-release will be authorized when other criteria are met. Efficacy has not been established for fibromyalgia, partial onset seizures, or restless legs syndrome; these uses are specifically designated as not medically necessary.

OpenPayer

Neurology - Lyrica CR Prior Authorization with Step Therapy Policy

Coverage Criteria for Pregabalin Extended-Release (Lyrica CR and Generics)

Billing and Coding Guidance

Provider Requirements, Prior Authorization, and Step Therapy

Key Definitions

Background