Pregabalin (Lyrica, Lyrica CR) medical necessity and prior authorization criteria
This policy defines medical necessity, prior authorization, step therapy, dosing limits, and approval durations for pregabalin (immediate- and controlled-release) across multiple indications for members under the payer's Commercial, HIM/ICHRA, and Medicaid lines of business.
For partial onset seizures, maximum dose revised to 14 mg/kg/day for members weighing < 30 kg per PI (replacing 420 mg maximum).
For neuropathic pain associated with cancer treatment, maximum dosage increased from 300 mg/day to 600 mg/day per NCCN.
Off-label criteria for restless legs syndrome (RLS) were added.
Commercial authorization duration changed to 12 months or duration of request, whichever is less.
ICHRA line of business was added to the policy.
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.