Medicare AdvantagePrior AuthHigh impact
Muscle Relaxants (Revised)
Humana·Pain Management, Neurology, Orthopedics +2 more·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana has revised its Muscle Relaxants step therapy policy (effective January 1, 2023, revised May 22, 2024) for Medicare Advantage plans. The policy now requires step therapy approval based on prior treatment criteria: members must have received previous treatment within the past 12 months with BOTH generic tizanidine tablets AND baclofen tablets before other muscle relaxants (Zanaflex, Amrix, chlorzoxazone, cyclobenzaprine ER, Fexmid, Lorzone, metaxalone, Lyvispah, orphenadrine injection) can be approved. Initial approvals are granted for the plan year duration or through clinical review.
Action Required
By May 22, 2024 (immediately, as this revision date has passed): Billing team must update preauthorization workflows and clinical review procedures to enforce the new step therapy criteria for all muscle relaxant requests on Humana Medicare Advantage plans. (1) Configure billing system to flag any muscle relaxant claim (Zanaflex, Amrix, chlorzoxazone, cyclobenzaprine ER, Fexmid, Lorzone, metaxalone, Lyvispah, orphenadrine injection) for prior authorization review. (2) Update prior authorization request templates to require documentation of prior 12-month treatment with BOTH generic tizanidine tablets AND baclofen tablets. (3) Train providers and front-desk staff to obtain and document this treatment history before submitting requests. (4) Notify all referring providers of the step therapy requirement via communication or EMR alerts. (5) Update internal denial templates to cite the step therapy criteria when claims are rejected for non-compliance. Failure to obtain proper prior authorization or verify step therapy criteria will result in claim denials and patient balance issues. Verify current policy version at http://apps.humana.com/tad/tad_new/home.aspx before processing.