Form Chch 2033 1 – Fill Out and Use This PDF

FIBROMYALGIA PRIOR AUTHORIZATION FORM

Coverage Policy: Lyrica, Cymbalta and Savella are covered for members with the diagnosis of fibromyalgia when ALL of the following criteria have been met. Other uses are not covered.

Documented failure* of the following:

1.ONE of the tricyclic antidepressants (TCA), AND

2.ONE of the muscle relaxants (e.g. cyclobenzaprine), AND

3.Documented non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), AND

4.At least TWO drugs from the following agents:

a.Any one SSRI, or

b.Tramadol, or

c.Gabapentin

*Failure is defined as intolerance or no clinical efficacy.

NON-covered uses are listed in the Prior Authorization criteria, which is available upon request.

>>>Requests for Lyrica or Cymbalta for diagnoses other than Fibromyalgia – please use the Lyrica or Cymbalta form <<<

PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES

FAX:Q1 (866) 738-9682 PHONE: (877) 215- 4100

Requesting Physician:		Office Contact:
Call Center ID:	Tax ID Number:	Plan ID:	Benefit:
Office Fax Number:		Phone Number:
Office Address:
MEMBER INFORMATION
Patient Name:		DOB:
Member ID#:		Date of Request:

MEDICATION INFORMATION

1. DRUG REQUESTED:	O Cymbalta	O Savella
O Lyrica

Please list specific past treatment trials and submit progress notes related to the request:

OTCA Drug:_____________ Dates used: ________ Therapeutic Outcome: __________________________

OMuscle Relaxant

2.Drug:_____________ Dates used: ________ Therapeutic Outcome: __________________________

OSSRI Drug:_____________ Dates used: _______ Therapeutic Outcome: __________________________

O	Tramadol	Dates used: ________	Therapeutic Outcome: ________________________
O	Gabapentin	Dates used: _______	Therapeutic Outcome: __________________________

Did member fail non-pharmacologic therapy? YES O NO O

3.Therapy Tried:_____________________________________________________________________

_________________________________________________________________________________

Additional Comments:

4.

Physician’s Signature:

CHCH 2033-1 (2/09)

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