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Drug Category: Musculoskeletal

Medication Class/Individual Agents: Muscle Relaxants - Skeletal

I. Prior-Authorization Requirements

 Muscle Relaxants - Skeletal

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

baclofen injection Gablofen # test  
baclofen intrathecal injection Lioresal test  
baclofen powder PA  
baclofen tablet test  
carisoprodol Soma PA  
carisoprodol / aspirin PA  
carisoprodol / aspirin / codeine PA  
chlorzoxazone 250 mg, 375 mg, 750 mg PA  
chlorzoxazone 500 mg Parafon Forte DSC # PA   - < 18 years
cyclobenzaprine 5 mg, 10 mg PA   - < 15 years
cyclobenzaprine 7.5 mg PA  
cyclobenzaprine extended-release Amrix PA  
dantrolene capsule Dantrium # test  
dantrolene injection solution Dantrium ^ test  
dantrolene injection suspension Ryanodex ^ test  
metaxalone Skelaxin PA  
methocarbamol Robaxin # PA   - < 16 years
orphenadrine PA   - < 18 years
orphenadrine / aspirin / caffeine PA  
orphenadrine powder PA  
tizanidine capsule Zanaflex PA  
tizanidine tablet Zanaflex # test  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

Precautions:

  • All agents within this class may cause drowsiness and dizziness. Patients should be advised of this and to avoid alcohol and other CNS depressants.
  • anticholinergic effects - baclofen, cyclobenzaprine, orphenadrine, tizanidine
  • cyclobenzaprine - structurally related to tricyclic antidepressants (TCAs); consider potential for similar adverse effects and drug interactions as with TCAs.
  • tizanidine - an alpha2 agonist structurally related to clonidine; may cause hypotension; hepatocellular injury reported – monitor LFTs.

Urine discoloration

  • orange or red-purple: chlorzoxazone
  • brown, black, or green: methocarbamol

Carisoprodol and carisoprodol-containing products

Please see the following link to find out more information regarding carisoprodol products (e.g., Letter to Prescribers)

http://www.mass.gov/eohhs/docs/masshealth/pharmacy/carisoprodol-letter.pdf.

 
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.
 

II. Therapeutic Uses

FDA-approved, for example:

  • spastic conditions
  • adjunctive treatment to rest, physical therapy, and other measures for the relief of discomforts associated with acute, painful musculoskeletal disorders.

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

 

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon the member's condition, diagnosis, and requested medication (see below).

 

baclofen powder

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

  

carisoprodol and carisoprodol-containing products

  • Documentation of all of the following is required:
    • medical records documenting an inadequate response, adverse reaction, or contraindication to all other centrally acting skeletal muscle relaxants; and
    • member is ≥ 18 years of age; and
    • one of the following:
      • the request is for an acute condition; or
      • clinical rationale for the use of carisoprodol for the treatment of a chronic condition.

 

orphenadrine powder

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

 

 

Spastic Conditions

Brand-name products (Dantrium, Zanaflex tablets) and tizanidine capsules 

  • Documentation of the following is required:
    • diagnosis of a spastic condition; and
    • an inadequate response, adverse reaction, or contraindication to dantrolene, baclofen, and tizanidine tablets; and
    • if request is for a brand name drug with an A-rated generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to a generic equivalent of the requested product; and
    • if request is for tizanidine capsules, the prescriber must provide medical necessity and compelling clinical rationale for capsule formulation (2 mg and 4 mg) or for dose (6 mg).

 

Musculoskeletal Conditions

Brand-name products (Flexeril, Parafon Forte DSC, Robaxin), chlorzoxazone 250 mg, 375 mg, 750 mg, cyclobenzaprine 7.5 mg, cyclobenzaprine extended-release, metaxalone, and orphenadrine/aspirin/caffeine

  • Documentation of the following is required:
    • diagnosis of musculoskeletal condition; and
    • an inadequate response, adverse reaction, or contraindication to cyclobenzaprine, orphenadrine, methocarbamol, and chlorzoxazone 500 mg; and
    • for orphenadrine/aspirin/caffeine, compelling clinical rationale why the combination product would offer a therapeutic advantage over the commercially available separate agents; and
    • if the request is for a brand name drug (with or without an A-rated generic) the prescriber must provide medical records documenting an inadequate response or adverse reaction to a generic equivalent of the requested drug.

Please note: requests for cyclobenzaprine extended-release require medical records of a trial with generic immediate release cyclobenzaprine. Chlorzoxazone 250 mg, 375 mg, and 750 mg requests require medical records of a trial with generic chlorzoxazone 500 mg.

SmartPA: Claims for metaxalone will usually process at the pharmacy without a PA request if the member has a history of MassHealth medical claims for a musculoskeletal disorder and paid MassHealth pharmacy claims for the following drugs: generic immediate release cyclobenzaprine, orphenadrine, methocarbamol, and chlorzoxazone.

 

chlorzoxazone 500 mg < 18 years old, cyclobenzaprine 5 mg, 10 mg < 15 years old, methocarbamol < 16 years old, and orphenadrine < 18 years old:

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • an inadequate response, adverse reaction, or contraindication to acetaminophen; and
    • one of the following:
      • an inadequate response or adverse reaction to two NSAIDs; or
      • contraindication to all NSAIDs.

 

  Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 09/2005

Last Revised Date: 08/2019


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Last updated 10/09/19