Effective June 1, 2016

UNIVERSITY OF MICHIGAN – LYRICA SOLUTION (pregabalin)

Some of the information needed to make a determination for coverage is not specifically requested on

the Michigan Prior Authorization Request Form for Prescription Drugs. To avoid delays in reviewing your

request, please make sure to include all of the following information.

Alternate Dosage Form

Lyrica oral capsule or Alternate Dosage Form (oral solution) – Bypass prior authorization for children ≤ 10 years of

age

1. Is there a medical need for an alternate dosage form? (circle or provide diagnosis/reason) -Bariatric surgery Drug/Form req’d: __________________

-Tube feeding Drug/Form req’d: __________________ Duration of tube placement: ___________

-Difficulty swallowing Drug/Form req’d: __________________

-Dysphagia Drug/Form req’d: __________________

-Other reason?___________________ Drug/Form req’d: _________ Duration: __________

Y N