Pharmacy Prior Authorization Criteria

Horizant (gabapentin enacarbil)

For diagnosis of Restless Legs Syndrome (RLS)
Indicated for the treatment of moderate-to-severe primary restless legs syndrome (RLS) in adults. Horizant is not recommended for patients who are required to sleep during the daytime and remain awake at night.
For diagnosis of Postherpetic Neuralgia (PHN)
Indicated for the management of postherpetic neuralgia (PHN) in adults.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Restless Legs Syndrome (RLS)

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Restless Legs Syndrome (RLS)

Patient has experienced an improvement in RLS disease symptoms (e.g., decrease in symptom onset or severity, improved sleep, or decrease in symptom intensity)

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Postherpetic Neuralgia (PHN)

AND

Patient has tried and had an inadequate response to a dose of at least 1,800 mg of generic gabapentin

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Postherpetic Neuralgia (PHN)

Patient has experienced an improvement in PHN disease symptoms (e.g., decrease in pain severity)

2024-01-29, 2023-02-28, 2022-02-08, 2021-03-03, 2020-02-19

Horizant Prescribing Information. Arbor Pharmaceuticals, LLC. Atlanta, GA. April 2020.
Silber MH, Buchfuhrer MJ, Earley CJ, Koo BB, Manconi M, Winkelman JW; Scientific and Medical Advisory Board of the Restless Legs Syndrome Foundation. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc. 2021 Jul;96(7):1921-1937. doi: 10.1016/j.mayocp.2020.12.026.
Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J of Neurol. 2010 Sep;17(9):1113-e88.
Johnson RW and Rice AS. Clinical Practice. Postherpetic neuralgia. N Engl J Med. 2014 Oct 16;371(16):1526-33.

While Horizant (gabapentin enacarbil) may improve patient convenience (twice daily rather than three times daily dosing), generic gabapentin is a more well-established, cost-effective therapy for PHN. The use of Horizant (gabapentin enacarbil) should be reserved for patients who have experienced treatment failure or intolerance to generic gabapentin. [3, 4]

2024-01-29: Annual Review, no criteria changes
2023-02-28: Annual Review - removal of step through ropinirole/pramipexole for RLS
2022-02-08: Annual Review - No criteria changes
2021-03-03: 2021 Annual Review, no changes to criteria.
2020-02-19: 2020 Annual Review, no changes to criteria.