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Ozobax DS — Blue Cross Blue Shield of Alabama

spasticity related to spinal cord injury or other spinal cord disease

Preferred products

  • generic baclofen tablets

Initial criteria

  • Patient has a diagnosis of spasticity resulting from multiple sclerosis AND the requested agent will be used for at least ONE of the following: • Flexor spasms and concomitant pain OR • Clonus OR • Muscular rigidity
  • AND ONE of the following: • The patient has an intolerance or hypersensitivity to generic baclofen tablets that is not expected to occur with the requested agent OR • The patient has an FDA labeled contraindication to generic baclofen tablets that is not expected to occur with the requested agent OR • The prescriber has provided information to support use of the requested agent over generic baclofen tablets
  • AND ONE of the following: • The patient has tried and had an inadequate response to another muscle relaxant (e.g., dantrolene, tizanidine) used for spasticity related to multiple sclerosis OR • The patient has an intolerance or hypersensitivity to ALL muscle relaxants used for spasticity related to multiple sclerosis OR • The patient has an FDA labeled contraindication to ALL muscle relaxants used for spasticity related to multiple sclerosis OR • The prescriber has provided information on why the patient is unable to use a solid dosage form (e.g., difficulty swallowing tablets or capsules, feeding tube)
  • OR Patient has a diagnosis of spasticity related to spinal cord injury or other spinal cord disease AND ONE of the following: • The patient has an intolerance or hypersensitivity to generic baclofen tablets that is not expected to occur with the requested agent OR • The patient has an FDA labeled contraindication to generic baclofen tablets that is not expected to occur with the requested agent OR • The prescriber has provided information to support use of the requested agent over generic baclofen tablets
  • AND ONE of the following: • The patient has tried and had an inadequate response to another muscle relaxant (e.g., dantrolene, pregabalin, tizanidine) used for spasticity related to spinal cord injuries or other spinal diseases OR • The patient has an intolerance or hypersensitivity to ALL muscle relaxants used for spasticity related to spinal cord injuries or other spinal cord diseases OR • The patient has an FDA labeled contraindication to ALL muscle relaxants used for spasticity related to spinal cord injuries or other spinal cord diseases