CurrentUnitedHealthcarePolicy N/A

Prior authorization for Soma (carisoprodol) and Soma compounds

Defines prior authorization requirements for coverage of Soma (carisoprodol) and compounded Soma products for beneficiaries under the payer's Medicaid protocol; primarily affects prescribers and pharmacies submitting PA requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization for Soma (carisoprodol) and Soma compounds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with documentation of trials and failures of two preferred skeletal muscle relaxants and supporting medical records to request approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2required prior failed agents

120maximum approved quantity per 30-day period

30dmaximum approval duration

365dlookback/approval period window

5ydocument retention by provider

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization for Soma (carisoprodol) and Soma compounds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with documentation of trials and failures of two preferred skeletal muscle relaxants and supporting medical records to request approval.

SourceLink

On This Page

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Initial Authorization

Covered when ALL of the following are met

Soma PA criteria: 1) Beneficiary has documented failure of at least two preferred skeletal muscle relaxants in the past 365 days; 2) Prescriber submits a completed prior authorization form including beneficiary identifiers, prescriber and pharmacy information, diagnosis with supporting documentation, and documentation of the two prior agents (drug names, dates of use, and reasons for discontinuation); 3) Required medical records, diagnostic evaluations, recent chart notes, and most recent related labs are provided and retained by the provider for five years; 4) Requested quantity does not exceed 120 tablets for a 30-day supply within a 365-day period.Maximum approval limited to 30 days (120 tablets) per 365 days.

An incomplete PA form may be returned or unprocessed; fax completed form to the PA fax number provided.

Coverage is not authorized unless the beneficiary has a documented failure of at least two preferred skeletal muscle relaxants within the prior 365 days. The prior trials must be documented on the completed prior authorization form and include drug names, dates of use, and reasons for discontinuation. Requests that do not show these two failed agents within the 365-day lookback will be denied.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Soma (carisoprodol) and carisoprodol compound products. Approval is limited to a maximum 30-day supply (up to 120 tablets) within a 365-day period.

Maximum approval: 30 days (up to 120 tablets) per 365 days
Fax completed form to: 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Step Therapy

Step Therapy Requirement

Requests must document that the member has tried and failed at least two preferred skeletal muscle relaxants within the past 365 days. Provide drug name, dates of use, and reason for discontinuing for each trial. Failure to meet the step therapy requirement may result in denial.

List two preferred agents tried within past 365 days with dates and reasons for discontinuation
Provide supporting clinical documentation of therapeutic outcome for each trial

Documentation Required

Required Documentation and Submission Instructions

Submit a completed prior authorization form with beneficiary identifiers, prescriber and pharmacy information, directions, quantity requested, diagnosis and supporting clinical documentation. Include copies of relevant medical records, diagnostic evaluations, recent chart notes, and related labs. The provider must retain copies of all documentation for five years. An incomplete form may be returned or left unprocessed.

Required: Beneficiary Medicaid ID, DOB, full name
Required: Prescriber name, NPI, phone, fax, signature and date
Required: Pharmacy name, Medicaid provider #, phone, fax
Required: Diagnosis and supporting documentation; recent chart notes and related labs
Retention: keep documentation for five years

Denial Risk

Incomplete Forms and Denial Risk

Incomplete or missing information on the prior authorization form (including absent trials of required agents or missing supporting records) may cause the request to be returned to the provider or not processed. Requests lacking evidence that the member failed the required step therapy agents within the lookback period may be denied.

Incomplete forms may be returned or left unprocessed
Requests may be denied if member has not failed the required two preferred agents in the prior 365 days

Initial Therapy Requirements

Initial therapy requirements

Initial coverage requires ALL of the following

Initial therapy for Soma: 1) Beneficiary must have failed at least two preferred skeletal muscle relaxants within the past 365 days with documentation of drug names, dates of use, and reasons for discontinuation; 2) Prescriber must submit a completed prior authorization form including diagnosis and supporting clinical documentation and provide all requested medical records and recent chart notes; 3) Approval is limited to a maximum 30-day supply (up to 120 tablets) within a 365-day period.Maximum approval 30 days (120 tablets) per 365 days.

Providers must retain documentation for five years; incomplete forms may be returned.

Step Therapy Documentation

Required trial	Documentation required	Reason(s) for discontinuation
Trial of preferred skeletal muscle relaxant #1 within past 365 days	Drug name and dates of use documented on PA form; supporting medical records attached	Provider must document the clinical reason the agent was discontinued (ineffectiveness, adverse effect, intolerance, etc.)
Trial of preferred skeletal muscle relaxant #2 within past 365 days	Drug name and dates of use documented on PA form; supporting medical records attached	Provider must document the clinical reason the agent was discontinued (ineffectiveness, adverse effect, intolerance, etc.)

OpenPayer

Prior authorization for Soma (carisoprodol) and Soma compounds

Coverage Criteria

Provider Actions and Requirements

Initial Therapy Requirements

Step Therapy Documentation

Coding and Limits

Quantity Limits