CurrentMass General Brigham Health PlanPolicy N/A

Skeletal Muscle Relaxants - Prior Authorization and Step Therapy

Defines pharmacy benefit step-therapy, quantity limit, and prior-authorization requirements for skeletal muscle relaxant prescriptions for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicySkeletal Muscle Relaxants - Prior Authorization and Step Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 25, 2018

Next Review DateN/A

Key ActionSubmit a prior authorization request with documentation of prior medication trials or inadequate response/side effect/allergy when step-therapy requirements are not met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval duration (max)

3first-line fills required

180 dayslookback period

carisoprodol 250mg, Lorzone, Amrixplan exclusions

Coverage Criteria

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Initial approval: First-line medications listed are covered without prior authorization.

Supported by policy statement that first-line pays at point-of-sale

Second-line payment conditions: Second-line medications will pay if the member has filled at least three different first-line medications OR has filled a second-line medication within the past 180 days OR has documented inadequate response, side effect, or allergy to at least three different preferred generic skeletal muscle relaxants.>= 3 different first-line fills within 180 days

See policy: documented inadequate response/side effect/allergy to >=3 preferred generics is an alternative route to approval

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required when the initial step-therapy requirements are not met at point-of-sale. Prescriptions that meet initial step-therapy will adjudicate automatically. If a prescription does not meet the requirements, it will deny at POS with a message that PA is required. Approvals are granted for 12 months when PA is approved.

PA approvals valid for 12 months
Point-of-sale (POS) denial occurs when step therapy unmet

Step Therapy

Initial Step-Therapy Requirements

First-line medications listed as preferred are covered without prior authorization. Second-line medications require evidence that the member has filled at least three different first-line agents or a second-line medication within the past 180 days before adjudication will occur without PA.

First-line agents = covered without PA
Second-line agents require ≥3 different first-line fills OR a second-line fill within past 180 days

Documentation Required

PA Submission Documentation

When submitting a prior authorization for a second-line medication, include documentation supporting inadequate response, intolerance, or allergy to at least three different preferred generic skeletal muscle relaxants. Include prior pharmacy fill history (dates, drug names, strengths), clinical notes describing lack of efficacy or adverse effects, and any relevant allergy documentation.

Documentation of prior trials (at least three different preferred generics)
Clinical rationale: inadequate response, side effects/intolerance, or allergy
Pharmacy fill records (dates, medication names, strengths)

Denial Risk

Point-of-Sale Denial if Step Therapy Unmet

Prescriptions that do not meet the initial step-therapy requirements will deny at point-of-sale and require submission of a prior authorization with the documentation above.

POS denial for step-therapy noncompliance triggers PA requirement
Submit complete PA documentation to avoid prolonged delay

Background

This policy defines step-therapy sequencing for skeletal muscle relaxants under the pharmacy benefit. First-line medications listed as preferred generic skeletal muscle relaxants (for example: chlorzoxazone, cyclobenzaprine, methocarbamol, orphenadrine formulations, baclofen, dantrolene, tizanidine, and carisoprodol 350 mg) are covered without prior authorization and will adjudicate at the point of sale when requirements are met. Second-line agents (including carisoprodol combination products and metaxalone) require that the member has either filled at least 3 different first-line medications within the past 180 days, has filled a second-line medication within the past 180 days, or has documented inadequate response, side effect, or allergy to at least three different preferred generic skeletal muscle relaxants before they will be approved without prior authorization.

Definitions

First-Line (definition and examples)

DefinitionMedications listed as first-line are covered without prior authorization

Examples (preferred generics)chlorzoxazone; cyclobenzaprine (Flexeril); methocarbamol (Robaxin); orphenadrine citrate ER; orphenadrine/ASA/Caffeine; baclofen (Lioresal); dantrolene (Dantrium); tizanidine (Zanaflex)

Policy noteFirst-line agents adjudicate at point-of-sale when step therapy met

Second-Line (definition and PA conditions)

DefinitionSecond-line medications require prior authorization unless the member meets step-therapy criteria

Payment conditionsWill pay if member has filled >=3 different first-line medications OR has filled a second-line medication within past 180 days

Failure criteriaAlso payable with documented inadequate response, side effect, or allergy to at least three different preferred generic skeletal muscle relaxants