CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 01/01/2021 VERIFIED: 02/26/2021 REVIEWED: 02/01/2021 SKELETAL MUSCLE RELAXANTS, NON-BENZODIAZEPINE Prior Authorization Override Request PHARMACY FAX # 844-256-2025 • Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _ NO _ YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy / /  No

(carisoprodol – generic of Soma) (carisoprodol compound – generic of Soma (carisoprodol compound with codeine – generic of compound) Soma compound with codeine) (chlorzoxazone 375 mg and 750 mg) (cyclobenzaprine ER – generic of Amrix) (cyclobenzaprine 7.5mg - generic of Fexmid) LORZONE (chlorzoxazone) (metaxalone – generic of Skelaxin) (orphenadrine - generic of Norflex) (orphenadrine compound - generic of Norgesic) (orphenadrine compound forte - generic of Norgesic (tizanidine capsules – generic of Zanaflex) Forte) LIORESAL (baclofen) PARAFON FORTE (chlorzoxazone) DANTRIUM (dantrolene) ROBAXIN (methocarbamol) ZANAFLEX (tizanidine capsules) SOMA (carisoprodol) SOMA COMPOUND (carisoprodol compound) SOMA COMPOUND W/CODEINE (carisoprodol FEXMID (cyclobenzaprine) compound with codeine) AMRIX (cyclobenzaprine ER) SKELAXIN (metaxalone) NORFLEX (orphenadrine) JORGESIC NORGESIC FORTE (orphenadrine compound forte)

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1

2

3

4

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 01/01/2021 VERIFIED: 02/26/2021 REVIEWED: 02/01/2021

CRITERIA FOR APPROVAL

1 Has the patient experienced an inadequate treatment response to at least a 30 Yes No day trial with a preferred medication (which does not require prior approval)? [If yes, then go to question 3.]

2 Is the patient unable to be changed to a preferred medication (which does not Yes No require prior approval) for any of the following acceptable reasons: A) Allergy, B) Contraindication or drug interaction, C) History of unacceptable or toxic side effects? [If no, then no further questions.]

3 Is the request for a carisoprodol (Soma) product or a combination product that Yes No contains carisoprodol? [If no, then no further questions.]

4 Would any other muscle relaxant or agent used to treat fibromyalgia or any Yes No musculoskeletal condition serve the clinical needs of the patient?

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)*

*In order to process this request, please complete all boxes completely.

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