Prior Authorization Criteria — TONMYA (cyclobenzaprine) sublingual tablets
Customize your policy alerts
Sign up for all Mississippi Division of Medicaid policy alerts
Know when Mississippi Division of Medicaid releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization requirements for TONMYA (cyclobenzaprine sublingual tablets) for treatment of fibromyalgia in adults under Mississippi Division of Medicaid.
No material clinical or coverage changes in this revision.
Coverage Criteria for TONMYA (cyclobenzaprine)
inv-01: Initial Authorization
Covered when ALL of the following are met
Initial authorization duration: 12 months.
inv-02: Re-Authorization
Covered for renewal when ALL of the following are met
Re-authorization duration: 12 months.
Initial Therapy
inv-10: Initial Therapy
Initial dosing and authorization expectations
Initial authorization: 12 months.
Continuation / Re-Authorization
inv-11: Continuation
Re-Authorization requirements
12 month re-authorization.
Provider Actions and Requirements
Prior authorization required for TONMYA
Prior authorization is required for TONMYA (cyclobenzaprine) and will be considered only when the clinical criteria for initial authorization or re‑authorization are met. Include the Universal PA Form and supporting clinical documentation when submitting the request.
Step therapy: required prior trials
Before TONMYA will be authorized, the patient must have tried and had an inadequate response, or have a documented contraindication or intolerance, to cyclobenzaprine oral tablets and to all preferred agents in the same PDL class.
Required documentation for PA submission
Submit the Universal PA Form along with supporting clinical documentation, including diagnosis of fibromyalgia, prior therapy trials (showing inadequate response or documented contraindication/intolerance), and prescribed dosing information.
Denial triggers and dose limit
Requests that exceed the maximum daily dose of 5.6 mg or that do not document the required prior trial/failure or documented contraindication/intolerance (or, for re‑authorization, documented positive clinical response) are at risk of denial.
- Maximum allowed daily dose: 5.6 mg
- Initial requests must document prior trials of cyclobenzaprine oral tablets and preferred PDL agents (or contraindication/intolerance)
- Re‑authorization must document positive clinical response
Dose and Coding Limits
Step Therapy Requirements
| Requirement | Details |
|---|---|
| Step | |
| Patient must have tried and had an inadequate response, or have a documented contraindication or intolerance, to cyclobenzaprine oral tablets before TONMYA will be authorized. |
Quantity Limits for TONMYA
Definitions
Background
TONMYA (cyclobenzaprine sublingual tablets) is a skeletal muscle relaxant indicated for the treatment of fibromyalgia in adults. The recommended starting dose is 2.8 mg once daily at bedtime for 14 days, increasing to 5.6 mg once daily thereafter; dosage adjustments are noted for geriatric patients and those with hepatic impairment per the package insert. TONMYA is available as 2.8 mg sublingual tablets. Prior authorization is required for TONMYA and will be considered when the clinical criteria in this policy are met.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.