CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 10/01/2020 VERIFIED: 11/20/2020 REVIEWED: 11/20/2020 NEUROPATHIC PAIN Prior Authorization Override Request PHARMACY FAX # 844-256-2025  Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _____ NO ______YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy __ / /  No

(clomipramine – generic of Anafranil) GRALISE (gabapentin) LYRICA CR (pregabalin extended-release)

ZTLIDO (lidocaine topical delivery system) (clomipramine)

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1 2 3 4

CRITERIA FOR APPROVAL

1 Has the patient experienced an inadequate treatment response to no less Yes No than a 30 day trial of at least TWO preferred medications (which do not require prior approval) in separate pharmacologic classes (e.g., Anticonvulsants: carbamazepine, gabapentin, oxcarbazepine, pregabalin; Antidepressants: amitriptyline, desipramine, doxepin, duloxetine, imipramine, nortriptyline; Analgesics: Lidocaine patch)? [If yes, then no further questions.] CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 10/01/2020 VERIFIED: 11/20/2020 REVIEWED: 11/20/2020

2 Is the patient unable to be changed to a preferred medication (which does Yes No not require prior approval) for any of the following acceptable reasons: A) Allergy, B) Contraindication or drug interaction, C) History of unacceptable or toxic side effects?

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)* *In order to process this request, please complete all boxes completely.

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