Gimoti (metoclopramide) nasal spray — Highmark

Preferred products

• generic metoclopramide oral tablets or ODT
• generic metoclopramide oral solution

Initial criteria

• age ≥ 18 years
• diagnosis of diabetic gastroparesis (ICD-10: E11.43, K31.84)
• prescriber attests the member does not have signs or symptoms of tardive dyskinesia
• member has experienced therapeutic failure or intolerance to one of the following plan-preferred agents: generic metoclopramide oral tablets or ODT OR generic metoclopramide oral solution OR member is not a candidate for oral dosage forms
• if age ≥ 65 years, member was titrated to a stable dose of metoclopramide oral tablets or metoclopramide oral solution at 10 mg four times daily before switching to Gimoti therapy

Reauthorization criteria

• prescriber attests the member has experienced positive clinical response to therapy
• member is using Gimoti for a new episode of diabetic gastroparesis
• member has undergone a 2 week drug holiday without Gimoti since its last administration
• prescriber attests the member does not have signs or symptoms of tardive dyskinesia
• prescriber attests that the benefits of extending therapy with Gimoti outweigh the risk of developing tardive dyskinesia

Approval duration

up to 12 weeks