CurrentCignaPolicy IP0392

Tizanidine capsules (2 mg, 4 mg, 6 mg) coverage

Defines medical necessity and authorization requirements for tizanidine 2 mg, 4 mg, and 6 mg capsules for Cigna-administered health benefit plans (employer plans noted). Affects providers seeking coverage for these capsule formulations.

Policy Summary

PayerCigna

PolicyTizanidine capsules (2 mg, 4 mg, 6 mg) coverage

Policy CodePolicy IP0392

Change TypeNo material changes

Effective DateApr 15, 2024

Next Review Date

Key ActionObtain documentation of failure, contraindication, or intolerance to tizanidine 1 mg or 2 mg tablet before requesting capsule coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2,4,6 mgcapsule strengths covered

≤12 moinitial authorization duration

≤12 moreauthorization duration

Yestablet trial required

employerplan type listed

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Covered when ALL of the following are met:

ALL of the following

Member is requesting tizanidine capsules (2 mg, 4 mg, or 6 mg).
Documentation of failure, contraindication, or intolerance to ONE of the following: tizanidine 1 mg tablet or tizanidine 2 mg tablet.
For continuation (reauthorization): documentation of beneficial response to tizanidine capsules.

Any other use is considered experimental, investigational, or unproven.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Tizanidine capsules are considered medically necessary when there is documentation of failure, contraindication, or intolerance to ONE of the following: tizanidine 1 mg tablet or tizanidine 2 mg tablet.

Affected products: tizanidine 2 mg, 4 mg, 6 mg capsules
Required prior step: trial of tizanidine tablets (1 mg or 2 mg) unless contraindicated or not tolerated

Step Therapy

Step Therapy Requirement

Step therapy: a trial of tizanidine tablets (1 mg or 2 mg) is required prior to approval of tizanidine capsules unless the tablet formulation is contraindicated or not tolerated.

Documented failure, intolerance, or contraindication to tablets must be provided to support capsule approval

Documentation Required

Documentation Expectations

Documentation should support that dosage, frequency, duration, and site of care are reasonable and clinically appropriate. Evidence-based literature, severity of condition, alternative treatments, and prior response to therapy should be considered. Receipt of sample product does not satisfy criteria requirements for coverage.

Include clinical rationale for capsule use and why tablet formulations are unsuitable when applicable
Provide prior therapy details (drug name, dose, duration, and reason for discontinuation)

Denial Risk

Non‑Covered Uses

Use of tizanidine for any indication other than management of spasticity (or other FDA‑approved indications where specified) is considered experimental, investigational, or unproven and is not covered.

Non‑covered: uses outside the accepted indications for tizanidine

Definitions

Tizanidine — definition entry for tizanidine hydrochloride

Generic nameTizanidine hydrochloride

Drug classCentral alpha-2-adrenergic agonist

Indication (covered)Management of spasticity

Clinical noteBecause of short duration of therapeutic effect, capsules should be reserved for daily activities and times when relief of spasticity is most important

Formulations referenced in policyTizanidine capsules (2 mg, 4 mg, 6 mg)

Step	Requirement
1	Trial of tizanidine tablet formulation required prior to coverage of tizanidine capsules: documentation of failure, contraindication, or intolerance to ONE of: tizanidine 1 mg tablet OR tizanidine 2 mg tablet.

Policy Summary

PayerCigna

PolicyTizanidine capsules (2 mg, 4 mg, 6 mg) coverage

Policy CodePolicy IP0392

Change TypeNo material changes

Effective DateApr 15, 2024

Next Review Date

Key ActionObtain documentation of failure, contraindication, or intolerance to tizanidine 1 mg or 2 mg tablet before requesting capsule coverage.

SourceLink

On This Page

OpenPayer

Tizanidine capsules (2 mg, 4 mg, 6 mg) coverage

Coverage Criteria

Provider Actions & Requirements

Background

Definitions

Initial Therapy Criteria

Continuation of Therapy

Step Therapy Requirements