Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Gabapentin Clinical Criteria Information Included in this Document Neurontin (gabapentin) • Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria • Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules • Logic diagram: a visual depiction of the clinical criteria logic • Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable • References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section. Gralise (gabapentin Extended Release) • Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria • Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules • Logic diagram: a visual depiction of the clinical criteria logic • Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable • References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section. March 29, 2019 Copyright © 2019 Health Information Designs, LLC 1 Horizant (gabapentin enacarbil) • Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria • Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules • Logic diagram: a visual depiction of the clinical criteria logic • Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable • References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated to include formulary statement (The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit TxVendorDrug.com/formulary/formulary-search.) on each ‘Drug Requiring PA’ tableAnnual review by staff March 29, 2019 Copyright © 2019 Health Information Designs, LLC 2 Texas Prior Authorization Program Clinical Criteria Gabapentin Gabapentin Drugs Requiring Prior Authorization The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit TxVendorDrug.com/formulary/formulary-search. Drugs Requiring Prior Authorization Label Name GCN GABAPENTIN 600 MG TABLET 94624 GABAPENTIN 800 MG TABLET 94447 GABAPENTIN 100 MG CAPSULE 00780 GABAPENTIN 300 MG CAPSULE 00781 GABAPENTIN 400 MG CAPSULE 00782 GABAPENTIN 250 MG/5 ML SOLN 13235 NEURONTIN 100 MG CAPSULE 00780 NEURONTIN 300 MG CAPSULE 00781 NEURONTIN 400 MG CAPSULE 00782 NEURONTIN 250 MG/5 ML SOLN 13235 NEURONTIN 600 MG TABLET 94624 NEURONTIN 800 MG TABLET 94447 March 29, 2019 Copyright © 2019 Health Information Designs, LLC 3 Texas Prior Authorization Program Clinical Criteria Gabapentin Gabapentin Clinical Criteria Logic 1. Is the client less than (<) 3 years of age? [ ] Yes (Deny) [ ] No (Go to #2) 2. Is the incoming request for a dose less than or equal to (≤) 1,400 mg per day? [ ] Yes (Go to #5) [ ] No (Go to #3) 3. Does the client have a diagnosis of chronic kidney disease in the last 365 days? [ ] Yes (Deny) [ ] No (Go to #4) 4. Does the client have a dialysis CPT code in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #5) 5. Does the client have a diagnosis of epilepsy/convulsions, neuropathic pain, migraine, restless leg syndrome, or fibromyalgia in the last 730 days? [ ] Yes (Approve - 365 days) [ ] No (Go to #6) 6.