Subject: Soma Limit Policy 206-H 10-2023

Drug

carisoprodol/aspirin/codeine phosphate

SOMA  (carisoprodol)

Policy:

FDA-APPROVED INDICATIONS
Soma
Soma is indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions in adults.

Limitations of Use
Soma should only be used for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use has not been established and because acute, painful musculoskeletal conditions are generally of short duration.

Carisoprodol/aspirin/codeine phosphate
Carisoprodol/aspirin/codeine phosphate tablets are indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions in adults.

Limitations of Use
Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, reserve carisoprodol/aspirin/codeine phosphate tablets for use in patients for whom alternative treatment options (e.g., non-opioid analgesics):
     •   Have not been tolerated, or are not expected to be tolerated,
     •   Have not provided adequate analgesia, or are not expected to
          provide adequate analgesia

Carisoprodol/aspirin/codeine phosphate tablets should only be used for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use has not been established and because acute, painful musculoskeletal conditions are generally of short duration.

INITIAL LIMIT QUANTITY   Limits should accumulate across all drugs and strengths up to highest quantity listed depending on   the order the claims are processed. Accumulation does not apply if limit is coded for daily dose.
Drug	1 Month Limit*	3 Month Limit
Carisoprodol/aspirin/codeine phosphate	168 tablets / 25 days	Does Not Apply**
Soma (carisoprodol)	84 tablets / 25 days	Does Not Apply**
* The duration of 25 days is used for a 30-day fill period to allow time for refill processing.
** These drugs are for short-term acute use; therefore, the mail limit will be the same as the retail limit. The intent is for prescriptions of the requested drug to be filled one month at a time, even if filled at mail order; there should be no 3 month supplies filled.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Soma [package insert]. Somerset, NJ: Meda Pharmaceuticals Inc.; May 2023.
2. Carisoprodol, aspirin, and codeine [package insert]. Orlando, FL: Ingenus Pharmaceuticals, LLC; April 2021.
3. Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2023. https://online.lexi.com. Accessed September 7, 2023.
4. Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 09/07/2023).

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 11, 2024