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Texas Prior Authorization Program Clinical Edit Criteria

Drug/Drug Class

Flexeril/Amrix (Cyclobenzaprine)

Clinical Edit Information Included in this Document

· · Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical edit

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Revision Notes

· · · · Added a new section to specify the drugs requiring prior authorization In the "Clinical Edit Criteria Logic" and "Clinical Edit Criteria Logic Diagram" sections, modified the "No" action to read "Go to 5" In the "Clinical Edit Criteria Supporting Tables" section, revised tables to specify the diagnosis codes pertinent to steps 3 and 4 of the logic diagram In the "Clinical Edit Criteria Supporting Tables" section, revised tables to specify the drug names and GCNs pertinent to steps 1, 2, and 5 of the logic diagram Added Step 5 in all sections to look for a history of a monoamine oxidase inhibitor in the last 14 days

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine)

Drugs Requiring Prior Authorization

Drugs Requiring Prior Authorization Label Name AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET GCN 97959 97960 12805 18020 98299

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine)

Clinical Edit Criteria Logic

1. Is the days supply greater than (>) 30 days for the current request and a cyclobenzaprine claim in the last 60 days? [ ] Yes (Go to #2) [ ] No (Go to #3) 2. Does the client have a history of 2 cyclobenzaprine claims in the last 60 days with a combined days supply of greater than (>) 30 days? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have a diagnosis of acute myocardial infarction in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #4) 4. Does the client have a diagnosis of cardiac conditions (cardiac arrhythmias, heart block, congenital long QT syndrome, torsade de points), hyperthyroidism, or heart failure in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #5) 5. Does the client have a history of a monoamine oxidase inhibitor (MAOI) in the last 14 days? [ ] Yes (Deny) [ ] No (Approve ­ 30 days)

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine)

Clinical Edit Criteria Logic Diagram

Step 1 Is the days supply > 30 days for the current request and a cyclobenzaprine claim in the last 60 days? Yes Step 2 Does the client have a history of 2 cyclobenzaprine claims in the last 60 days with a combined days supply of greater than 30 days? Yes

Deny Request

No

No

Step 3 Does the client have a diagnosis of acute myocardial infarction in the last 180 days? Yes Deny Request

No

Step 4 Does the client have a diagnosis of cardiac conditions (cardiac arrythmias, heart block, congenital long QT syndrome, torsade de points), hyperthyroidism, or heart failure in the last 730 days? Yes

Deny Request

No

Step 5 Does the client have a history of a monoamine oxidase inhibitor (MAOI) in the last 14 days? Yes

Deny Request

No

Approve Request (30 days)

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine)

Clinical Edit Criteria Supporting Tables

Step 1 (days supply greater than 30 days for the current request and a cyclobenzaprine claim) Required quantity: 1 plus incoming request Look back timeframe: 60 days Label Name AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET GCN 97959 97960 12805 18020 98299

Step 2 (two cyclobenzaprine claims with a combined days supply of more than 30 days) Required quantity: 2 Look back timeframe: 60 days Label Name AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET GCN 97959 97960 12805 18020 98299

Step 3 (diagnosis of acute myocardial infarction) Required diagnosis: 1 Look back timeframe: 180 days ICD-9 Code 410 4100 41000 41001 41002 4101 41010 Description ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL AMI ANTEROLATERAL,UNSPEC AMI ANTEROLATERAL, INIT AMI ANTEROLATERAL,SUBSEQ ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL AMI ANTERIOR WALL,UNSPEC

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Step 3 (diagnosis of acute myocardial infarction) Required diagnosis: 1 Look back timeframe: 180 days ICD-9 Code 41011 41012 4102 41020 41021 41022 4103 41030 41031 41032 4104 41040 41041 41042 4105 41050 41051 41052 4106 41060 41061 41062 4107 41070 41071 41072 4108 41080 41081 41082 4109 41090 41091 41092 Description AMI ANTERIOR WALL, INIT AMI ANTERIOR WALL,SUBSEQ ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL AMI INFEROLATERAL,UNSPEC AMI INFEROLATERAL, INIT AMI INFEROLATERAL,SUBSEQ ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL AMI INFEROPOST, UNSPEC AMI INFEROPOST, INITIAL AMI INFEROPOST, SUBSEQ ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL AMI INFERIOR WALL,UNSPEC AMI INFERIOR WALL, INIT AMI INFERIOR WALL,SUBSEQ ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL AMI LATERAL NEC, UNSPEC AMI LATERAL NEC, INITIAL AMI LATERAL NEC, SUBSEQ TRUE POSTERIOR WALL INFARCTION TRUE POST INFARCT,UNSPEC TRUE POST INFARCT, INIT TRUE POST INFARCT,SUBSEQ SUBENDOCARDIAL INFARCTION SUBENDO INFARCT, UNSPEC SUBENDO INFARCT, INITIAL SUBENDO INFARCT, SUBSEQ ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES AMI NEC, UNSPECIFIED AMI NEC, INITIAL AMI NEC, SUBSEQUENT ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE AMI NOS, UNSPECIFIED AMI NOS, INITIAL AMI NOS, SUBSEQUENT

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure)

Required diagnosis: 1 Look back timeframe: 730 days

ICD-9 Code 242 2420 24200 24201 2421 24210 24211 2422 24220 24221 2423 24230 24231 2424 24240 24241 2428 24280 24281 2429 24290 24291 426 4260 4261 42610 42611 42612 42613 4262 4263 4264 4265 42650 42651 42652

Description THYROTOXICOSIS WITH OR WITHOUT GOITER TOXIC DIFFUSE GOITER TOX DIF GOITER NO CRISIS TOX DIF GOITER W CRISIS TOXIC UNINODULAR GOITER TOX UNINOD GOIT NO CRIS TOX UNINOD GOIT W CRISIS TOXIC MULTINODULAR GOITER TOX MULTNOD GOIT NO CRIS TOX MULTNOD GOIT W CRIS TOXIC NODULAR GOITER UNSPECIFIED TYPE TOX NOD GOITER NO CRISIS TOX NOD GOITER W CRISIS THYROTOXICOSIS FROM ECTOPIC THYROID NODULE THYROTOX-ECT NOD NO CRIS THYROTOX-ECT NOD W CRIS THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN THYRTOX ORIG NEC NO CRIS THYROTOX ORIG NEC W CRIS THYROTOXICOSIS WITHOUT MENTION OF GOITER OR OTHER CAUSE THYROTOX NOS NO CRISIS THYROTOX NOS W CRISIS CONDUCTION DISORDERS ATRIOVENT BLOCK COMPLETE ATRIOVENTRICULAR BLOCK OTHER AND UNSPECIFIED ATRIOVENT BLOCK NOS ATRIOVENT BLOCK-1ST DEGR ATRIOVEN BLOCK-MOBITZ II AV BLOCK-2ND DEGREE NEC LEFT BB HEMIBLOCK LEFT BB BLOCK NEC RT BUNDLE BRANCH BLOCK BUNDLE BRANCH BLOCK OTHER AND UNSPECIFIED BUNDLE BRANCH BLOCK NOS RT BBB/LFT POST FASC BLK RT BBB/LFT ANT FASC BLK

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure)

Required diagnosis: 1 Look back timeframe: 730 days

ICD-9 Code 42653 42654 4266 4267 4268 42681 42682 42689 4269 427 4270 4271 4272 4273 42731 42732 4274 42741 42742 4275 4276 42760 42761 42769 4278 42781 42789 4279 428 4280 4281 4282 42820 42821 42822 42823

Description BILAT BB BLOCK NEC TRIFASCICULAR BLOCK OTHER HEART BLOCK ANOMALOUS AV EXCITATION OTHER SPECIFIED CONDUCTION DISORDERS LOWN-GANONG-LEVINE SYND LONG QT SYNDROME CONDUCTION DISORDER NEC CONDUCTION DISORDER NOS CARDIAC DYSRHYTHMIAS PAROX ATRIAL TACHYCARDIA PAROX VENTRIC TACHYCARD PAROX TACHYCARDIA NOS ATRIAL FIBRILLATION AND FLUTTER ATRIAL FIBRILLATION ATRIAL FLUTTER VENTRICULAR FIBRILLATION AND FLUTTER VENTRICULAR FIBRILLATION VENTRICULAR FLUTTER CARDIAC ARREST PREMATURE BEATS PREMATURE BEATS NOS ATRIAL PREMATURE BEATS PREMATURE BEATS NEC OTHER SPECIFIED CARDIAC DYSRHYTHMIAS SINOATRIAL NODE DYSFUNCT CARDIAC DYSRHYTHMIAS NEC CARDIAC DYSRHYTHMIA NOS HEART FAILURE CONGESTIVE HEART FAILURE, UNSPECIFIED LEFT HEART FAILURE SYSTOLIC HEART FAILURE UNSPECIFIED SYSTOLIC HEART FAILURE ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure)

Required diagnosis: 1 Look back timeframe: 730 days

ICD-9 Code 4283 42830 42831 42832 42833 4284 42840 42841 42842 42843 4289 7802 7943 79430 79431 9971

Description DIASTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE HEART FAILURE NOS SYNCOPE AND COLLAPSE NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF CARDIOVASCULAR SYSTEM ABN CARDIOVASC STUDY NOS ABNORM ELECTROCARDIOGRAM SURG COMPL-HEART

Step 5 (history of monoamine oxidase inhibitor therapy) Required quantity: 1 Look back timeframe: 14 days Label Name AZILECT 0.5MG TABLET AZILECT 1MG TABLET EMSAM 6MG/24 HOURS PATCH EMSAM 9MG/24 HOURS PATCH EMSAM 12MG/24 HOURS PATCH MARPLAN 10MG TABLET PHENELZINE SULFATE 15MG TABLET SELEGILINE HCL 5MG CAPSULE SELEGILINE HCL 5MG TABLET TRANYLCYPROMINE 10MG TABLET ZYVOX 100MG/5ML SUSPENSION ZYVOX 200MG/100ML IV SOLN ZYVOX 600MG/300ML IV SOLN GCN 27081 24654 26612 26613 26614 16416 16417 15603 15600 16418 26871 26872 26873

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Step 5 (history of monoamine oxidase inhibitor therapy) Required quantity: 1 Look back timeframe: 14 days Label Name ZYVOX 600MG TABLET GCN 26870

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Flexeril/Amrix (Cyclobenzaprine)

Clinical Edit Criteria References

1. Gold Standard. Cyclobenzaprine monograph. Tampa, FL: Clinical pharmacology. October 7, 2004. Available at: http://clinicalpharmacology.com/Forms/drugoptions.aspx?cpnum=155&n=Cyclo benzaprine. Accessed on October 12, 2011.

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Texas Prior Authorization Program Clinical Edits

Flexeril/Amrix (Cyclobenzaprine)

Publication History

The Publication History records the publication iterations and revisions to this document. Notes for the most current revision are also provided in the Revision Notes on the first page of this document.

Publication Date 01/31/2011 10/17/2011 Notes Initial publication and posting to website · Added a new section to specify the drugs requiring prior authorization · In the "Clinical Edit Criteria Logic" and "Clinical Edit Criteria Logic Diagram" sections, modified the "No" action to read "Go to 5" · In the "Clinical Edit Criteria Supporting Tables" section, revised tables to specify the diagnosis codes pertinent to steps 3 and 4 of the logic diagram · In the "Clinical Edit Criteria Supporting Tables" section, revised tables to specify the drug names and GCNs pertinent to steps 1, 2, and 5 of the logic diagram · Added Step 5 in all sections to look for a history of a monoamine oxidase inhibitor in the last 14 days

October 17, 2011

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