Vanadom — Medical Mutual

Acute musculoskeletal condition

Initial criteria

Patient is age ≥ 16 years; AND
Requested medication will not be used in combination with an opiate and a benzodiazepine; AND
Provider attests that they have reviewed the patient’s controlled substance history by running an Ohio Automated Rx Reporting System (OARRS) Report (or respective prescription monitoring program in the provider’s state of practice if available) and has no concerns; AND
Patient has tried and failed at least TWO of the following: baclofen, cyclobenzaprine, metaxalone, tizanidine, orphenadrine, dantrolene, or methocarbamol; AND
Patient does not have a history of acute intermittent porphyria; AND
For brand Soma requests, patient has tried generic carisoprodol AND cannot use the generic due to a formulation difference in inactive ingredients (e.g. dyes, fillers, preservatives, etc.) between the brand and generic

Patient is age ≥ 16 years; AND
Requested medication will not be used in combination with an opiate and a benzodiazepine; AND
Provider attests that they have reviewed the patient’s controlled substance history by running an Ohio Automated Rx Reporting System (OARRS) Report (or respective prescription monitoring program in the provider’s state of practice if available) and has no concerns; AND
Patient has tried and failed at least TWO of the following: baclofen, cyclobenzaprine, metaxalone, tizanidine, orphenadrine, dantrolene, or methocarbamol; AND
Second request for the medication is over 3 months from first request AND for a different acute incident or episode than first request; AND
Patient does not have a history of acute intermittent porphyria; AND
For brand Soma requests, patient has tried generic carisoprodol AND cannot use the generic due to a formulation difference in inactive ingredients (e.g. dyes, fillers, preservatives, etc.) between the brand and generic

30 days (initial); 30 days (extended, only 1 additional approval allowed in 365 days)