Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria
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1 Flexeril/Amrix (Cyclobenzaprine) Clinical Edit Criteria Drug/Drug Class: Flexeril/Amrix (Cyclobenzaprine) Superior HealthPlan follows the guidance of the Texas Vendor Drug Program (VDP) for all clinical edit criteria. Superior has adjusted the clinical criteria to ease the prior authorization process regarding this clinical edit. The hyperthyroidism, cardiac condition and heart failure lookback period was shortened from 730 to 365 days. Syncope diagnosis as a basis for denial was removed. Using yellow borders and highlights, Superior has marked the ease in the edit step within the clinical edit criteria diagram and in the diagnosis code tables. The original clinical edit can be referenced at the Texas Vendor Drug Program website located at Clinical Edit Information Included in this Document: Drugs included in the edit: a list of medications included in this clinical edit logic. Logic diagram: a visual depiction of the clinical edit criteria logic. Diagnosis codes or drugs in step logic: a list of diagnosis codes or drug information and additional step logic, claims and lookback period information. Clinical Edit References: clinical edit references as provided by the Texas Vendor Drug Program. Publication history: to track when the eased criteria was put into production and any updates since this time. Please note: All tables are provided by original Texas Vendor Drug Program Flexeril/Amrix (Cylcobenzaprine) Edit. Eased criteria outlined or highlighted in yellow. Drugs Requiring Prior Authorization: Drugs Requiring Prior Authorization Label Name GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET FEXMID 7.5 MG TABLET SuperiorHealthPlan.com SHP_ A Page 1 of 11
2 Superior HealthPlan Clinical Edit Logic Diagram- Flexeril/Amrix (Cyclobenzaprine): Step 1 Is the client < 15 years of age or > 65 years of age? Deny Deny Request Step 2 Step 3 Is the days supply >30 days for the current request and is there a cyclobenzaprine claim in the last 60 days? Does the client have a history of 2 cyclobenzaprine claims in the last 60 days with a combined days supply > 30 days? Deny Request No Step 4 Does the client have a diagnosis of acute myocardial infarction in the last 180 days? Deny Request No Step 5 Does the client have a diagnosis of cardiac conditions, hyperthyroidism or heart failure in the last 365 days? Deny Request No Step 6 Does the client have a claim for an MAOI in the last 14 days? Deny Request No Approve Request (30 days) Page 2 of 11
3 Diagnosis Codes and Drugs Used in Flexeril/Amrix (Cyclobenzaprine) Step Logic: Step 2 (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 GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET FEXMID 7.5 MG TABLET Step 3 (two cyclobenzaprine claims with a combined days supply of more than 30 days) Required quantity: 2 Look back timeframe: 60 days Label Name GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET FEXMID 7.5 MG TABLET ICD-10 Code I2101 I2102 I2109 Step 4 (diagnosis of acute myocardial infarction) Description Look back timeframe: 180 days ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING LEFT MAIN CORONARY ARTERY ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING LEFT ANTERIOR DESCENDING CORONARY ARTERY ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER CORONARY ARTERY OF ANTERIOR WALL Page 3 of 11
4 ICD-10 Code I2111 I2119 I2121 I2129 I213 I214 I220 I221 I222 I228 I229 Step 4 (diagnosis of acute myocardial infarction) Description Look back timeframe: 180 days ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING RIGHT CORONARY ARTERY ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER CORONARY ARTERY OF INFERIOR WALL ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING LEFT CIRCUMFLEX CORONARY ARTERY ST ELEVATION (STEMI) MYOCARDIAL INFARCTION INVOLVING OTHER SITES ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION SUBSEQUENT ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF ANTERIOR WALL SUBSEQUENT ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF INFERIOR WALL SUBSEQUENT NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION SUBSEQUENT ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF OTHER SITES SUBSEQUENT ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) ICD-9 Code Description 242 THYROTOXICOSIS WITH OR WITHOUT GOITER 2420 TOXIC DIFFUSE GOITER TOX DIF GOITER NO CRISIS TOX DIF GOITER W CRISIS 2421 TOXIC UNINODULAR GOITER TOX UNINOD GOIT NO CRIS TOX UNINOD GOIT W CRISIS 2422 TOXIC MULTINODULAR GOITER TOX MULTNOD GOIT NO CRIS TOX MULTNOD GOIT W CRIS 2423 TOXIC NODULAR GOITER UNSPECIFIED TYPE TOX NOD GOITER NO CRISIS TOX NOD GOITER W CRISIS Page 4 of 11
5 Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) 2424 THYROTOXICOSIS FROM ECTOPIC THYROID NODULE THYROTOX-ECT NOD NO CRIS THYROTOX-ECT NOD W CRIS 2428 THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN THYRTOX ORIG NEC NO CRIS THYROTOX ORIG NEC W CRIS 2429 THYROTOXICOSIS WITHOUT MENTION OF GOITER OR OTHER CAUSE THYROTOX NOS NO CRISIS THYROTOX NOS W CRISIS 426 CONDUCTION DISORDERS 4260 ATRIOVENT BLOCK COMPLETE 4261 ATRIOVENTRICULAR BLOCK OTHER AND UNSPECIFIED ATRIOVENT BLOCK NOS ATRIOVENT BLOCK-1ST DEGR ATRIOVEN BLOCK-MOBITZ II AV BLOCK-2ND DEGREE NEC 4262 LEFT BB HEMIBLOCK 4263 LEFT BB BLOCK NEC 4264 RT BUNDLE BRANCH BLOCK 4265 BUNDLE BRANCH BLOCK OTHER AND UNSPECIFIED BUNDLE BRANCH BLOCK NOS RT BBB/LFT POST FASC BLK RT BBB/LFT ANT FASC BLK BILAT BB BLOCK NEC TRIFASCICULAR BLOCK 4266 OTHER HEART BLOCK 4267 ANOMALOUS AV EXCITATION 4268 OTHER SPECIFIED CONDUCTION DISORDERS LOWN-GANONG-LEVINE SYND LONG QT SYNDROME CONDUCTION DISORDER NEC 4269 CONDUCTION DISORDER NOS 427 CARDIAC DYSRHYTHMIAS 4270 PAROX ATRIAL TACHYCARDIA 4271 PAROX VENTRIC TACHYCARD 4272 PAROX TACHYCARDIA NOS Page 5 of 11
6 Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) 4273 ATRIAL FIBRILLATION AND FLUTTER ATRIAL FIBRILLATION ATRIAL FLUTTER 4274 VENTRICULAR FIBRILLATION AND FLUTTER VENTRICULAR FIBRILLATION VENTRICULAR FLUTTER 4275 CARDIAC ARREST 4276 PREMATURE BEATS PREMATURE BEATS NOS ATRIAL PREMATURE BEATS PREMATURE BEATS NEC 4278 OTHER SPECIFIED CARDIAC DYSRHYTHMIAS SINOATRIAL NODE DYSFUNCT CARDIAC DYSRHYTHMIAS NEC 4279 CARDIAC DYSRHYTHMIA NOS 428 HEART FAILURE 4280 CONGESTIVE HEART FAILURE, UNSPECIFIED 4281 LEFT HEART FAILURE 4282 SYSTOLIC HEART FAILURE UNSPECIFIED SYSTOLIC HEART FAILURE ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 4283 DIASTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE 4284 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 4289 HEART FAILURE NOS Page 6 of 11
7 7943 Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF CARDIOVASCULAR SYSTEM ABN CARDIOVASC STUDY NOS ABNORM ELECTROCARDIOGRAM 9971 SURG COMPL-HEART ICD-10 Code E0500 E0501 E0510 E0511 E0520 E0521 E0530 E0531 E0540 E0541 E0580 E0581 E0590 E0591 I440 I441 I442 I4430 I4439 I444 I445 I4460 I4469 I447 I450 Description THYROTOXICOSIS WITH DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM THYROTOXICOSIS WITH DIFFUSE GOITER WITH THYROTOXIC CRISIS OR STORM THYROTOXICOSIS WITH TOXIC SINGLE THYROID NODULE WITHOUT THYROTOXICOSIS WITH TOXIC SINGLE THYROID NODULE WITH THYROTOXICOSIS WITH TOXIC MULTINODULAR GOITER WITHOUT THYROTOXICOSIS WITH TOXIC MULTINODULAR GOITER WITH THYROTOXICOSIS FROM ECTOPIC THYROID TISSUE WITHOUT THYROTOXICOSIS FROM ECTOPIC THYROID TISSUE WITH THYROTOXICOSIS FACTITIA WITHOUT THYROTOXIC CRISIS OR STORM THYROTOXICOSIS FACTITIA WITH OTHER THYROTOXICOSIS WITHOUT OTHER THYROTOXICOSIS WITH THYROTOXICOSIS, UNSPECIFIED WITHOUT THYROTOXIC CRISIS OR STORM THYROTOXICOSIS, UNSPECIFIED WITH THYROTOXIC CRISIS OR STORM ATRIOVENTRICULAR BLOCK, FIRST DEGREE ATRIOVENTRICULAR BLOCK, SECOND DEGREE ATRIOVENTRICULAR BLOCK, COMPLETE UNSPECIFIED ATRIOVENTRICULAR BLOCK OTHER ATRIOVENTRICULAR BLOCK LEFT ANTERIOR FASCICULAR BLOCK LEFT POSTERIOR FASCICULAR BLOCK UNSPECIFIED FASCICULAR BLOCK OTHER FASCICULAR BLOCK LEFT BUNDLE-BRANCH BLOCK, UNSPECIFIED RIGHT FASCICULAR BLOCK Page 7 of 11
8 I4510 I4519 I452 I453 I454 I455 I456 I4581 I4589 I459 I462 I468 I469 I470 I471 I472 I479 I480 I481 I482 I483 I484 I4891 I4892 I4901 I4902 I491 I492 I493 I4940 I4949 I495 I498 I499 I501 I5020 Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) UNSPECIFIED RIGHT BUNDLE-BRANCH BLOCK OTHER RIGHT BUNDLE-BRANCH BLOCK BIFASCICULAR BLOCK TRIFASCICULAR BLOCK NONSPECIFIC INTRAVENTRICULAR BLOCK OTHER SPECIFIED HEART BLOCK PRE-EXCITATION SYNDROME LONG QT SYNDROME OTHER SPECIFIED CONDUCTION DISORDERS CONDUCTION DISORDER, UNSPECIFIED CARDIAC ARREST DUE TO UNDERLYING CARDIAC CONDITION CARDIAC ARREST DUE TO OTHER UNDERLYING CONDITION CARDIAC ARREST, CAUSE UNSPECIFIED RE-ENTRY VENTRICULAR ARRHYTHMIA SUPRAVENTRICULAR TACHYCARDIA VENTRICULAR TACHYCARDIA PAROXYSMAL TACHYCARDIA, UNSPECIFIED PAROXYSMAL ATRIAL FIBRILLATION PERSISTENT ATRIAL FIBRILLATION CHRONIC ATRIAL FIBRILLATION TYPICAL ATRIAL FLUTTER ATYPICAL ATRIAL FLUTTER UNSPECIFIED ATRIAL FIBRILLATION UNSPECIFIED ATRIAL FLUTTER VENTRICULAR FIBRILLATION VENTRICULAR FLUTTER ATRIAL PREMATURE DEPOLARIZATION JUNCTIONAL PREMATURE DEPOLARIZATION VENTRICULAR PREMATURE DEPOLARIZATION UNSPECIFIED PREMATURE DEPOLARIZATION OTHER PREMATURE DEPOLARIZATION SICK SINUS SYNDROME OTHER SPECIFIED CARDIAC ARRHYTHMIAS CARDIAC ARRHYTHMIA, UNSPECIFIED LEFT VENTRICULAR FAILURE UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE Page 8 of 11
9 I5021 I5022 I5023 I5030 I5031 ACUTE SYSTOLIC (CONGESTIVE) HEART FAILURE CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE DIASTOLIC (CONGESTIVE) HEART FAILURE I5032 I5033 I5040 I5041 I5042 I5043 I509 I97110 I97111 I97120 I97121 I97130 I97131 I97190 I97191 I97710 I97711 I97790 I97791 I9788 I9789 R001 Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE HEART FAILURE, UNSPECIFIED POSTPROCEDURAL CARDIAC INSUFFICIENCY FOLLOWING CARDIAC SURGERY POSTPROCEDURAL CARDIAC INSUFFICIENCY FOLLOWING OTHER SURGERY POSTPROCEDURAL CARDIAC ARREST FOLLOWING CARDIAC SURGERY POSTPROCEDURAL CARDIAC ARREST FOLLOWING OTHER SURGERY POSTPROCEDURAL HEART FAILURE FOLLOWING CARDIAC SURGERY POSTPROCEDURAL HEART FAILURE FOLLOWING OTHER SURGERY OTHER POSTPROCEDURAL CARDIAC FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY OTHER POSTPROCEDURAL CARDIAC FUNCTIONAL DISTURBANCES FOLLOWING OTHER SURGERY INTRAOPERATIVE CARDIAC ARREST DURING CARDIAC SURGERY INTRAOPERATIVE CARDIAC ARREST DURING OTHER SURGERY OTHER INTRAOPERATIVE CARDIAC FUNCTIONAL DISTURBANCES DURING CARDIAC SURGERY OTHER INTRAOPERATIVE CARDIAC FUNCTIONAL DISTURBANCES DURING OTHER SURGERY OTHER INTRAOPERATIVE COMPLICATIONS OF THE CIRCULATORY SYSTEM, NOT ELSEWHERE CLASSIFIED OTHER POSTPROCEDURAL COMPLICATIONS AND DISORDERS OF THE CIRCULATORY SYSTEM, NOT ELSEWHERE CLASSIFIED BRADYCARDIA, UNSPECIFIED Page 9 of 11
10 R9430 R9431 ABNORMAL RESULT OF CARDIOVASCULAR FUNCTION STUDY, UNSPECIFIED ABNORMAL ELECTROCARDIOGRAM [ECG] [EKG] Step 5 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) Removed diagnosis codes 7802 SYNCOPE AND COLLAPSE R55 SYNCOPE AND COLLAPSE Step 6 (history of monoamine oxidase inhibitor therapy) Required quantity: 1 Look back timeframe: 14 days Label Name GCN AZILECT 0.5MG TABLET AZILECT 1MG TABLET EMSAM 12MG/24 HOURS PATCH EMSAM 6MG/24 HOURS PATCH LINEZOLID 600MG TABLET LINEZOLID 600MG/300ML IV SOLN MARPLAN 10MG TABLET NARDIL 15MG TABLET PARNATE 10MG TABLET PHENELZINE SULFATE 15MG TABLET SELEGILINE HCL 5MG CAPSULE SELEGILINE HCL 5MG TABLET TRANYLCYPROMINE 10MG TABLET ZELAPAR 1.25 MG ODT TABLET ZYVOX 100MG/5ML SUSPENSION ZYVOX 600MG TABLET ZYVOX 600MG/300ML IV SOLN Page 10 of 11
11 Clinical Edit References: 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on April 1, Micromedex [online database]. Available at Accessed on April 1, ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, Amrix Prescribing Information. North Wales, PA. Teva Pharmaceuticals. May a American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society 2015;63(11): Publication History: Publication Date Notes 09/28/15 Clinical edit added. 07/01/07 Modified edit to shorten lookback period of hyperthyroidism, cardiac condition and heart failure from 730 to 365 days and to remove syncope diagnosis as a basis for denial. Reference tables, diagnosis codes, references and publication table per UMCM Chapter 3 requirements. All tables are cross referenced to VDP criteria. Page 11 of 11
Prior Authorization Flexeril/Amrix (cyclobenzaprine) 2017
Drugs Requiring Prior Authorization Label Name GCN AMRIX ER 15 MG CAPSULE 97959 AMRIX ER 30 MG CAPSULE 97960 CYCLOBENZAPRINE 10 MG TABLET 18020 CYCLOBENZAPRINE 5 MG TABLET 12805 CYCLOBENZAPRINE 7.5 MG
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