Horizant (gabapentin enacarbil) — Highmark
Restless Leg Syndrome (RLS), moderate-to-severe
Preferred products
- generic gabapentin immediate-release
- generic pregabalin
Initial criteria
- age ≥ 18 years
- diagnosis of RLS (ICD-10: G25.81), classified as moderately to severely active
- prescriber attests that exacerbating factors of RLS have been addressed (alcohol use, caffeine consumption, antihistaminergic, serotonergic, antidopaminergic medication use, and untreated obstructive sleep apnea)
- one of the following: (a) serum ferritin ≤ 75 ng/mL or transferrin saturation < 20% AND prescriber attests member is being treated with iron therapy (for example IV ferric carboxymaltose, IV low molecular weight iron dextran, IV ferumoxytol, or ferrous sulfate) OR (b) serum ferritin > 75 ng/mL or transferrin saturation ≥ 20%
- therapeutic failure or intolerance to all of the following plan-preferred products: generic gabapentin immediate-release AND generic pregabalin
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months