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PAxx Lyrica/ pregabalin


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U.S. Doctors Resources, L.L.C.

PRIOR AUTHORIZATION


DRUG THERAPY:

Lyrica® / pregabalin


DISEASE

Peripheral Neuropathy Disease


MEDICAL REVIEW and DECISION:

The Prior Authorization for the above drug has been denied pending the following:
Gabapentin is available Free of Deductible.


1. For neuropathic pain/ fibromyalgia, similar results are noted with gabapentin primary therapy[1], high dose methyl-colbamin injections [2]; then followed by treatments for fibromyalgia[3].

2. Contact Benefit Manager for Referral for Anabolic Protocol for adult sufferers.

Pending (1.) and (2.) the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030


Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.






IDENTIFICATION:



Demographics Health Insurance/ Credit Card
Member Name:____________________________________ Member Name on the Card:_____________________________________
Insurance ID:____________________________________ Issuing Service: VISA, MC, Discover _________________
Date of Birth:____________________________________ Number:____________________________________
Street Address:____________________________________ Expiration:____________________________________
City/ State/ Zip code:____________________________________CVV Code:____________________________________
Telephone Number:____________________________________
Signature of Employee/ Insured:

_________________________________
Signature of Treating Physician:___________________________________





References:
1. Physician Desk Reference

2. http://www.ncbi.nlm.nih.gov/pubmed/26404562 Laryngoscope. 2016 Feb;126(2):357-66. doi: 10.1002/lary.25636. Epub 2015 Sep 25. The efficacy of gabapentin/pregabalin in improving pain after tonsillectomy: A meta-analysis. Hwang SH1, Park IJ1, Cho YJ1, Jeong YM1, Kang JM1.

2. http://www.ncbi.nlm.nih.gov/pubmed/8021696 J Neurol Sci. 1994 Apr;122(2):140-3. Ultra-high dose methylcobalamin promotes nerve regeneration in experimental acrylamide neuropathy. Watanabe T1, Kaji R, Oka N, Bara W, Kimura J.

3. http://www.ncbi.nlm.nih.gov/pubmed/17289417 Growth Horm IGF Res. 2007 Feb;17(1):82-8. Epub 2007 Feb 6. Is further evaluation for growth hormone (GH) deficiency necessary in fibromyalgia patients with low serum insulin-like growth factor (IGF)-I levels?Yuen KC1, Bennett RM, Hryciw CA, Cook MB, Rhoads SA, Cook DM.


Signed b.n.r. Benefit Manager ___________________________________ date:__________


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