COVERED USES:

FDA Approved Indications:

• Diabetic peripheral neuropathic pain
• Fibromyalgia
• Generalized anxiety disorder
• Major depressive disorder.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

1. Treatment of Diabetic Peripheral Neuropathic Pain; OR
2. Trial and failure of two formulary antidepressants for the treatment of Major Depressive Disorder; OR
3. Trial and failure of two formulary medications used in the treatment of anxiety excluding benzodiazepines; OR
4. Treatment of fibromyalgia requires a trial of at least 30 days and failure of
   1. Gabapentin
   2. One SSRI/SNRI (e.g. fluoxetine)

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.