CurrentUnitedHealthcarePolicy N/A

Prior Authorization for Soma (carisoprodol) and Soma Compound

Prior authorization requirements for coverage of Soma (carisoprodol) and Soma Compound for UnitedHealthcare Medicaid beneficiaries; applies to prescribers and pharmacies requesting PA.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization for Soma (carisoprodol) and Soma Compound

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form documenting failure of two preferred skeletal muscle relaxants in the past 365 days and required supporting medical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysMaximum approval per 365 days

2Preferred failures required

5Record retention (years)

1PA form fax

Coverage Criteria

Initial Authorization

Covered when ALL of the following are met:

Prior therapy: Beneficiary has failed at least two preferred skeletal muscle relaxants in the past 365 days.

Must provide supporting clinical documentation indicating therapeutic outcome of trials and failures.

Documentation: Completed prior authorization form with beneficiary and prescriber information, diagnosis, dates of prior therapies and reasons for discontinuation, and copies of medical records and recent labs.

Provider must retain copies of all documentation for five years.

Quantity/Duration: Approval limited to a maximum 30-day supply (up to 120 tablets) within a 365-day period.30 days / 120 tablets per 365 days

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization for Soma (carisoprodol) and Soma Compound

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form documenting failure of two preferred skeletal muscle relaxants in the past 365 days and required supporting medical records.

SourceLink

On This Page

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Use beyond the maximum 30-day / 120-tablet limit per 365 days or use without documented failure of two preferred skeletal muscle relaxants within the past 365 days is not eligible for approval under this protocol and will require medical justification on the PA form. The PA form must be completed in full and include supporting clinical documentation (drug names, dates of use, reasons for discontinuation, and copies of relevant medical records and recent labs).

An incomplete form may be returned and missing supporting documentation may result in denial; providers should retain copies of all required documentation for five years and fax the completed form to the number on the PA form.

Preferred agent	Dates tried	Reason for discontinuation
Preferred agent 1 (name as documented)
Preferred agent 2 (name as documented)

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization is required for Soma and Soma Compound. Approval is limited to a maximum 30-day supply (120 tablets) per 365 days.

Drugs: Soma® (Carisoprodol); Soma® Compound
Quantity limit: 120 tablets per 365 days

Step Therapy

Step Therapy Requirement

Request must document that the beneficiary has failed at least two preferred skeletal muscle relaxants within the past 365 days prior to submission.

Required: documented trials of two preferred agents with dates and outcomes
Timeframe: within the past 365 days

Documentation Required

Required Documentation

A completed PA form and supporting clinical documentation are required for review. This must include beneficiary and prescriber details, diagnosis, dates of use and reasons for discontinuation for the two preferred agents, and copies of relevant medical records.

PA form fields: beneficiary name, Medicaid ID, DOB, prescriber name, NPI, contact info, pharmacy name and provider #
Diagnosis and supporting documentation (e.g., recent chart notes, diagnostic evaluations, labs)
List of two preferred skeletal muscle relaxants with dates of use and reasons for discontinuation
Prescriber's signature and date

Denial Risk

Incomplete Submission / Insufficient Prior Therapy — Denial Risk

Incomplete submissions may be returned and failure to provide required supporting documentation may result in denial. Requests lacking documentation of trials of two preferred agents within the past 365 days are subject to denial.

Incomplete PA form may be returned
Missing medical records or missing trial details may lead to denial
Insufficient prior therapy (fewer than two documented preferred agent failures within 365 days) may result in denial

Billing Rule

Quantity/Duration Limit Exceeded

Requests exceeding the quantity/duration limits (greater than 30 days or more than 120 tablets per 365 days) may be denied.

Quantity/Duration limit: 30 days (120 tablets) per 365 days

Background

Soma (carisoprodol) is a skeletal muscle relaxant indicated for short-term symptomatic relief of acute musculoskeletal pain. This policy enforces prior trials of preferred agents and limits treatment duration to reduce the risk of misuse and adverse events.

Approval is limited to short-term use only — a maximum 30-day supply (up to 120 tablets) within a 365-day period — and requires documentation that the beneficiary failed at least two preferred skeletal muscle relaxants in the prior 365 days before Soma or Soma Compound will be authorized.

OpenPayer

Prior Authorization for Soma (carisoprodol) and Soma Compound

Coverage Criteria

Initial Therapy

Step Therapy Requirements

Coding & Limits

Quantity Limits

Provider Actions & Documentation

Definitions

Background

Site of Care