Medical Policy

Effective Date:01/01/2014 Title:Metaxalone
Revision Date: Document:BI443:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Metaxalone requires prior authorization.

2)    Metaxalone is used along with rest, physical therapy, and other measures for relief of musculoskeletal pain associated with acute, painful musculoskeletal conditions.

Medical Statement

1)    Metaxalone requires prior authorization.

2)    Metaxalone is considered medically necessary for members who have a recent (within past 90 days) trial of at least two (2) other skeletal muscle relaxants (chlorzoxazone, cyclobenzaprine, carisoprodol, orphenadrine, methacarbamol, or tizanidine).

Limits

Metaxalone is limited to no more than 4 tablets per day.

Reference

1)    Clinical Pharmacology.  metaxolone – accessed online 12/31/2013.

2)    Oregon Evidence Based Practice Center.  Drug Class Review on Skeletal Muscle Relaxants.  May 2005.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.