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November 1, 2005
 
MEDICAID INFORMATION RELEASE 2005-35
 
TO:                 Prescribing Providers, Pharmacists, Pharmacies, Hospitals, and Long-Term Care Facilities
 
FROM:           Randy May, Deputy Administrator
 
SUBJECT:      PRIOR AUTHORIZATION CRITERIA FOR SKELETAL MUSCLE RELAXANT DRUG CLASS
 
Drug/Drug Class:
SKELETAL MUSCLE RELAXANT AGENTS
Implementation Date:
Effective for dates of service on or after December 1, 2005
 

Idaho Medicaid is designating preferred agents and therapeutic criteria for the Skeletal Muscle Relaxant drug class as part of the Enhanced Prior Authorization Program.   Beginning December 1, 2005, the preferred agents for the Skeletal Muscle Relaxant drug class will be the following:
 
Preferred Agent(s)
Non-preferred Agents
Baclofen
Chlorzoxazone
Cyclobenzaprine HCL
Dantrium
Flexeril® (5mg only)
Methocarbamol
Orphenadrine Citrate
Tizanidine HCL
Carisoprodol (Soma®)
Flexeril®
Parafon Forte®
Robaxin®
Robaxin Forte®
Norflex®
Skelaxin®
Zanaflex®
 
Therapeutic Criteria
Documented failure of two (2) preferred agents (based on adequate trial of at least one week per agent) will be required before non-preferred agents will be authorized.
Additional carisoprodol (Soma®) criteria:
1)      Carisoprodol use will be limited to 34 days or less*.
2)      Concurrent carisoprodol and opioid use will require prior authorization.
3)      Additional prior authorization requests for carisoprodol, after initial approval, will not be granted for at least six (6) months following the last day of previous therapy.
* A 30 day taper period for chronic users will be allowed as requested by physician.
 
Questions regarding the Prior Authorization program may be referred to Medicaid Pharmacy at (208) 364-1829.

 
A current listing of all the preferred agents by drug class and prior authorization criteria is also available online at www.medicaidpharmacy.idaho.gov.
 
IDAHO MEDICAID PROVIDER HANDBOOK
This Information Release does not replace information in your Idaho Medicaid Handbook.
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