Triptan Quantity Limit
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1 *- Florida Healthy Kids Triptan Quantity Limit Override(s) Quantity Limit Approval Duration 1 year Oral Tablets Axert (almotriptan) tablets Relpax (eletriptan) tablets 6 tablets (6.25 mg) 12 tablets (12.5 mg) 6 tablets (20 40 mg) 12 tablets (40 mg). Frova (frovatriptan) tablets 9 tablets Amerge (naratriptan) tablets 9 tablets Maxalt (rizatriptan) tablets Maxalt (rizatriptan) MLT tablets 12 tablets 3 tablets/unit of use carrying case PAGE 1 of 5 09/12/2017 WEB-PEC
2 *- Florida Healthy Kids Imitrex (sumatriptan) tablets 9 tablets Zomig (zolmitriptan) tablets Zomig (zolmitriptan) ZMT Treximet (sumatriptan/naproxen sodium) tablets 3 tablets (5 mg) 6 tablets (2.5 mg) 9 tablets Nasal Sprays Imitrex (sumatriptan) Nasal Spray Box of 6 inhalers 6 inhalers per Onzetra Xsail (sumatriptan) nasal powder Box of 8 pouches, each pouch contains two 11mg nosepieces to 12 inhalers per. 1 kit per rolling 30 days to 2 kits per rolling 30 days if override are met. Zomig (zolmitriptan) Nasal Spray Box of 6 inhalers 6 inhalers per to 12 inhalers per. PAGE 2 of 5 09/12/2017
3 *- Florida Healthy Kids Injectables Alsuma (sumatriptan) Injection 2 pre-filled syringe auto injectors 4 syringes per to 8 syringes per. Imitrex (sumatriptan) Injection 2 syringes/stat dose systems 4 cartridges per to 8 cartridges per. Box of 5 single dose vials 5 vials per rolling 30 days. to10 vials per. Sumatriptan Injection 1, 2, 5 or 10 single dose vials 5 vials per rolling 30 days to 10 vials per Sumavel (sumatriptan) DosePro 6 pre-filled units 4 unit devices per Zembrace SymTouch (sumatriptan) 1 pre-filled syringe autojector Box of 4 pre-filled syringe autojectors to 8 unit devices per if override are met 8 syringes per to 16 syringes per 30 days if override are met PAGE 3 of 5 09/12/2017
4 *- Florida Healthy Kids Transdermal Zecuity (sumatriptan iontophoretic transdermal system) Box of 4 patches 4 patches per to 8 patches per QUANTITY LIMITS Injectable Override Quantity Limits: Alsuma (sumatriptan) - up to 8 syringes per Imitrex (sumatriptan) Injection - up to 8 cartridges or 10 vials per Sumatriptan Injection up to 10 vials per Sumavel (sumatriptan) DosePro up to 8 unit devices per Zembrace SymTouch (sumatriptan) up to 16 syringes per Oral Tablet Override Quantity Limits: Quantities up to 18 standard dosage units per Nasal Spray Override Quantity Limits: Quantities up to 12 standard dosage units per Quantities up to 2 kits per (Onzetra Xsail) Transdermal Override Quantity Limits: Quantities up to 8 patches per APPROVAL CRITERIA Qualified patients may be eligible for coverage of quantities above the standard available quantity. Quantity limit overrides will be considered for people who meet all of the following criteria: I. Individual has a diagnosis of migraine headache, AND II. Individual has had a previous trial and an inadequate response to one of the following daily preventive therapies (AAHA 2012/2015, ICSI 2013): A. A tricyclic antidepressant [such as but not limited to amitriptyline, doxepin ]; OR B. A beta blocker [such as but not limited to metoprolol tartrate, propranolol, timolol, atenolol, nadolol, nebivolol]; OR C. A calcium channel blocker [such as but not limited to nicardipine, verapamil]; OR D. An ACE inhibitor [such as but not limited to lisinopril]; OR PAGE 4 of 5 09/12/2017
5 *- Florida Healthy Kids E. An angiotensin receptor blocker (ARB) [such as but not limited to candesartan]; OR F. An alpha 2 agonist [such as but not limited to guanfacine (AAHA 2012)]; OR G. An antiepileptic [such as but not limited to divalproex sodium, sodium valproate, topiramate, carbamazepine, gabapentin]; OR H. Other select antidepressants [such as but not limited to venlafaxine]; OR I. Cyproheptadine (Periactin). State name Date effective State Specific Mandates Mandate details (including specific bill if applicable) Key References: Clinical Pharmacology [database online]. Tampa, : Gold Standard, Inc.: URL: Updated periodically. DailyMed. Package inserts. U.S. National Library of Medicine, National Institutes of Health website. Accessed January 30, DrugPoints System (electronic version). Truven Health Analytics, Greenwood Village, CO. Updated periodically. Lexi-Comp ONLINE with AHFS, Hudson, Ohio: Lexi-Comp, Inc.; 2017; Updated periodically. PAGE 5 of 5 09/12/2017
Triptans Quantity Limit Program Summary
Triptans Quantity Limit Program Summary FDA APPROVED INDICATIONS AND DOSAGE 1-13,14,23,24 Agents Amerge (naratriptan) 1, 2.5 tablets Axert (almotriptan) 6.25, 12.5 tablets migraine attacks with/without
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Page: 1 of 6. Aimovig (erenumab-aooe) injection, Ajovy (fremanezumab-vfrm) injection, Emgality (galcanezumab-gnim)
Page: 1 of 6 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Last Review Date: November 30, 2018 Description Aimovig (erenumab-aooe) injection, Ajovy (fremanezumab-vfrm)
Clinical Policy: Triptans Reference Number: CP.CPA.217 Effective Date: Last Review Date: Line of Business: Commercial
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Clinical Policy: Sumatriptan Reference Number: CP.CPA.260 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.260 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Sumatriptan Reference Number: CP.HNMC.260 Effective Date: Last Review Date: Line of Business: Medicaid Medi-Cal
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Drug Therapy Guidelines Applicable Medical Benefit Effective: 5/1/18 Pharmacy- Formulary 1 x Next Review: 3/19 Pharmacy- Formulary 2 x Date of Origin: 8/29/06 Triptans: almotriptan, Amerge, Axert, Frova,
Abortive Agents. Available Strengths. Formulary Limits. Tablet: 5mg, 10mg ODT: 5mg, 10 mg 25mg, 50mg, 100mg. 5mg/act, 20mg/act
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Migraine Therapy P&T DATE: 9/12/2017 CLASS: Neurological Disorders REVIEW HISTORY 12/16, 9/15, 2/15, 2/10, 5/07 LOB: MCL
UTILIZATION MANAGEMENT CRITERIA
SUMATRIPTAN (ALSUMA, IMITREX, SUMAVEL DOSEPRO, ZECUITY ) UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: BRAND (generic) NAME: Serotonin 5-HT1 receptor agonists Imitrex (sumatriptan), Alsuma (sumatriptan),
Page: 1 of 5. Sumatriptan Tablets and Nasal Spray (Imitrex) / sumatriptan and naproxen sodium (Treximet tablets)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 0 Subject: Sumatriptan (Imitrex / Treximet) Page: 1 of 5 Last Review Date: September 12, 2014 Sumatriptan
Clinical Policy: Triptans Reference Number: CP.CPA.217 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.217 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
ABORTIVE AGENTS. Average cost per 30 days. Form Limits SEROTONIN AGONISTS $ $ Reserved for treatment failure to either Sumatriptan PA; QL
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Migraine Therapy P&T DATE: 12/11/2018 CLASS: Neurological Disorders REVIEW HISTORY 9/17, 12/16, 9/15, 2/15, 2/10, LOB: MCL
Literature Scan: Triptans
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.11 Subject: Sumatriptan Injection Page: 1 of 6 Last Review Date: March 17, 2017 Sumatriptan Injection
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.60 Subject: Migranal Nasal Spray Page: 1 of 5 Last Review Date: November 30, 2018 Migranal Nasal Spray
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 05.70.10 Subject: Sumatriptan Page: 1 of 5 Last Review Date: December 2, 2016 Sumatriptan Description Sumatriptan
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