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.

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.

Ozobax

• Documentation of all of the following is required:
  • appropriate diagnosis; and
  • one of the following:
    • an inadequate response or adverse reaction to baclofen tablets; or
    • clinical rationale for the use of a liquid formulation.

Spastic Conditions

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

• Documentation of the following is required:
  • diagnosis of a spastic condition; and
  • if request is for brand name Dantrium or Zanaflex, the prescriber must provide documentation of 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 documentation of all of the following:
    • an inadequate response, adverse reaction, or contraindication to baclofen, and tizanidine tablets; and
    • 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, Robaxin 750 mg), 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
  • one of the following:
    • member is ≥ 18 years of age; or
    • inadequate response or adverse reaction to acetaminophen and two NSAIDS or contraindication to acetaminophen and NSAIDS; 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.