Effective Date

Date of Origin 

7/1/2023

almotriptan

Tablet

Acute treatment of migraine attacks in adults with a history of migraine with or without aura 

Acute treatment of migraine headache pain in adolescents age 12 to 17 years with a history of migraine with or without aura, and who have migraine attacks usually lasting 4 hours or more

Amerge® 
(naratriptan)*

Tablet

Acute treatment of migraine attacks with or without aura in adults

*generic available

1

Frova® 
(frovatriptan)*

Tablet

Acute treatment of migraine attacks with or without aura in adults

*generic available

3

Imitrex®
(sumatriptan)* 

Nasal spray

Acute treatment of migraine with or without aura in adults

*generic available

5

Imitrex®*, Sumatriptan

Subcutaneous injection

Acute treatment of migraine with or without aura in adults

Acute treatment, cluster headache episodes in adults

*generic available

4

Imitrex®
(sumatriptan)*

Tablet

Acute treatment of migraine with or without aura in adults

*generic available

6

Maxalt®
(rizatriptan)*

Maxalt MLT®
(rizatriptan orally disintigrating tablet)* 

Tablet

Acute treatment of migraine with or without aura in adults and in pediatric patients 6 to 17 years old

*generic available

7

Onzetra® Xsail®
(sumatriptan)

Nasal powder/Nosepiece

Acute treatment of migraine with or without aura in adults

20 ; 8

Relpax®
(eletriptan)*

Tablet

Acute treatment of migraine with or without aura in adults

*generic available

8 ; 9

Tosymra®
(sumatriptan)

Nasal spray

Acute treatment of migraine with or without aura in adults

11 ; 23

Treximet®
(sumatriptan/naproxen sodium)* 

Tablet

Acute treatment of migraine with or without aura in adults and pediatric patients 12 years of age and older

*generic available

12 ; 9

Zembrace® SymTouch®
(sumatriptan)

Injection

Acute treatment of migraine with or without aura in adults

13 ; 19

Zomig®
(zolmitriptan)*

Nasal spray

Acute treatment of migraine with or without aura in adults and pediatric patients 12 years of age and older

*generic available

11 ; 15

Zomig®
(zolmitriptan)* 

Zomig ZMT® 
(zolmitriptan orally disintigrating tablet)*   

Tablet

Acute treatment of migraine with or without aura in adults

*generic available

10 ; 14

Triptans

All products in the program are indicated for the acute treatment of migraine attacks with or without aura in adults.(1-15)

• Use only after a clear diagnosis of migraine has been established
• These products are not intended for prophylactic therapy of migraine attacks, or for management of hemiplegic or basilar migraine.

While the incidence is rare, the triptans have been associated with angina, myocardial infarction (MI), cardiac arrhythmias, hypertension, or stroke, particularly when they were used in patients with vascular risk factors. Triptans should be used with extreme caution in these patients or those with a suspected history of coronary artery disease. Triptans should not be used in patients with uncontrolled hypertension, ischemic heart disease, peripheral vascular disease, or cerebrovascular disease. Triptans should not be used within 24 hours of treatment with another 5-HT1 agonist, or an ergotamine-containing or ergot-type medication like dihydroergotamine or methysergide.(1-15)

The Medical Letter Treatment Guidelines (2017) – Drugs for Migraine states that a triptan is the drug of choice for moderate to severe migraine. The short-acting oral serotonin (5-HT1B/1D) receptor agonists (triptans) sumatriptan (Imitrex, and others), almotriptan (Axert, and generics), eletriptan (Relpax), rizatriptan (Maxalt, and generics), and zolmitriptan (Zomig,and generics) are similar in efficacy. Onset of pain relief generally occurs 30-60 minutes after administration. The longer-acting oral triptans naratriptan (Amerge, and generics) and frovatriptan (Frova, and generics) have a slower onset of action and lower initial response rate than other triptans, but they are better tolerated. Patients with migraine who have nausea or vomiting may not be able to take an oral triptan. Intranasal triptan formulations have a more rapid onset of action than oral tablets, but their efficacy is partially dependent on GI absorption of the portion of the dose that is swallowed. Use of sumatriptan nasal powder (Onzetra Xsail) results in a faster rise in sumatriptan plasma concentrations and higher peak concentrations than use of a similar dose of sumatriptan nasal spray, suggesting that a larger portion of the dose is absorbed intranasally with the powder. Subcutaneously administered sumatriptan relieves pain faster (in about 10 minutes) and more effectively than other triptan formulations, but it causes more adverse effects.(19)

The Institute for Clinical Systems Improvement Guideline Diagnosis and Treatment of Migraine Headache states that triptans are considered to have equal efficacy and are more effective at halting migraine pain at mild levels than if the headache is more severe. Clinicians should consider using subcutaneous sumatriptan or intranasal zolmitriptan as a first line option for the treatment of cluster headaches.(18)

The American Academy of Neurology 2010 Guideline: Acute and preventive pharmacologic treatment of cluster headache state that sumatriptan subcutaneous injection and zolmitriptan nasal spray are recommended for acute treatment of cluster headaches.(16) American Headache Society (2016): Treatment of Cluster Headaches: Since the publication of the 2010 American Academy of Neurology review, there are no new data from randomized, double-blind, controlled trials that contribute to determining the efficacy or safety for a number of acute treatments, including specifically sumatriptan and zolmitriptan. For acute treatment, sumatriptan subcutaneous, zolmitriptan nasal spray, and high flow oxygen remain the treatments with a Level A recommendation.(21)

American Headache Society (2015): The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies: The specific medications – triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan [oral, nasal spray, injectable, transcutaneous patch], zolmitriptan [oral and nasal spray]) are effective (Level A). The evidence base for medication efficacy should be considered along with potential medication side effects, potential adverse events, patient-specific contraindications to use of a particular medication, and drug-to-drug interactions when deciding which medication to prescribe for acute therapy of a migraine attack.(20) An assessment of new migraine treatments by the American Headache society (2018; updated 2021) reaffirms previous migraine guidelines. The update lists triptans, dihydroergotamine, the oral gepants [Nurtec® ODT (rimegepant) and Ubrelvy® (ubrogepant)], and Reyvow (lasmiditan) as effective treatment of moderate or severe acute attacks and mild to moderate attacks that respond poorly to nonsteroidal anti-inflammatory drugs, non-opioid analgesics, acetaminophen, or caffeinated combinations (e.g., aspirin/acetaminophen/caffeine). The recommendation also remains that prescribers must consider medication efficacy and potential medication-related adverse effects when prescribing acute medications for migraine.(22,30)

The American Headache Society (AHS) and the American Academy of Neurology (AAN) suggest the following agents for the prevention of migraine:(17)

• Established as effective (Level A)
  • Antiepileptic drugs (AEDs)
    • Divalproex
    • Valproate
    • Topiramate
  • Beta blockers
    • Metoprolol
    • Propranolol
    • Timolol
  • Triptans
    • Frovatriptan for short term menstrually associated migraines (MAMs) prevention
• Probably effective (Level B)
  • Antidepressants
    • Amitriptyline
    • Venlafaxine
  • Beta blockers
    • Atenolol
    • Nadolol
  • Triptans
    • Naratriptan, zolmitriptan for short term MAMs prevention

The European Headache Federation and WHO consensus article (2019) states the following:(23)

• Individuals with migraine headaches should almost always be managed in primary care. The exception being chronic migraine, which likely requires specialist management.
• Any headache not responding satisfactorily in primary care should be referred to a specialist
• In adults and children, regular high frequency use (>2 day/week) of acute medication risks the development of medication-overuse headache
• Treatment of episodic acute migraine headaches should be approached in a step wise manner and should treat three attacks at each step before moving to the next step if needed:
  • Step 1:
    • Use non-opioid analgesics, plus an antiemetic when needed.
  • Step 2 for adults:
    • Use triptan products.
    • Triptans should not be used regularly on greater than or equal to10 days/month to avoid the risk of medication overuse headaches.
    • Triptan efficacy is highly variable between individuals, so patients should try different triptans and formulations. Sumatriptan subcutaneous injection should be considered when all other triptans are ineffective.
    • When nausea is present, zolmitriptan nasal spray or sumatriptan subcutaneous injection may be preferred.
  • Step 2 for children and adolescents:
    • Failure of Step 1 in children should lead to specialist referral.  No specific anti-migraine drugs have shown efficacy in children under 12 years of age
    • Failure of Step 2 in adolescents (12-17 years of age), the following have shown efficacy and are approved:
      • Sumatriptan nasal spray
      • Zolmitriptan nasal spray
• For episodic migraine prophylaxis:
  • Indication for migraine prophylaxis include:
    • Attacks cause disability on two or more days per month
    • And acute therapy has been optimized but does not prevent this, or is poorly tolerated, or there is a risk of over-frequent use of acute therapy, even when it is effective
    • And the patient is willing to take daily medication.
    • Failure of acute therapy is an indication for migraine prophylaxis.
    • For children: frequent absence from school.
  • Migraine prophylaxis agents may take 2-3 months to show efficacy.
  • Children requiring prophylactic medication should be referred to a specialist.
  • Medications which are effective in adult prophylaxis of episodic migraine include:
    • Beta blockers:
      • Atenolol, bisoprolol, metoprolol, propranolol
    • Amitriptyline
    • Topiramate
    • Candesartan
    • Sodium valproate
    • Flunarizine
    • CGRP
  • Onabotulinum toxin A is not effective in episodic migraine.
  • When prophylaxis therapy fails:
    • Failure may be due to subtherapeutic dosage or duration of therapy.
    • Failure of one therapy does not predict the failure of another therapy.
    • Review of the following are recommended:
      • Diagnosis
      • Adherence
      • Other medications, especially for medication overuse headache causes
    • The prophylaxis therapy should be discontinued if it fails to show clear benefit.
    • If all prophylaxis therapies fail, a specialist should be referred.
• Chronic migraine management:
  • Chronic migraine patients should be referred to a specialist.
  • Medications with efficacy in chronic migraine include:
    • Topiramate
    • Onabotulinum A
    • CGRP
• Cluster headache patients should be referred to specialists.
  • Acute therapies include:
    • Triptans:
      • Sumatriptan subcutaneous injection
      • Sumatriptan nasal spray
      • Zolmitriptan nasal spray
    • Oxygen
  • Transition and maintenance therapies include:
    • Prednisone
    • Greater occipital nerve blockade
    • Verapamil
    • Lithium carbonate
    • Topiramate
  • Neuromodulation is another treatment option.
  • Failure of one prophylactic therapy does not predict the failure of other therapies
  • Combination prophylaxis therapy can be considered though the potential for toxicity is high.
  • For chronic cluster headache patients, long-term prophylaxis therapy may be needed.
• Medication overuse headache (MOH)
  • Prevention is preferred.
  • The four objectives of management are:
    • Stop the overused medication.
    • Recovery from MOH.
    • Review and reassess the underlying headache disorder
    • Prevent relapse while allowing acceptable use of medications
  • Comorbidities may also require management

The European Headache Federation guideline states the following on combining migraine prophylaxis therapy:(24)

• In episodic migraine, it’s suggested to stop oral prophylaxis migraine agents before starting CGRPs, unless the patient previously had chronic migraine prior to prophylaxis.  In such patients, the suggestion is to add CGRP to the ongoing oral prophylaxis therapy.
• In chronic migraine, it’s suggested to add CGRP to ongoing oral prophylaxis therapy.
• In chronic migraine patients on onabotulinum A therapy and are receiving inadequate treatment response, it’s suggested to stop onabotulinum A therapy before starting CGRPs.
• In patients with chronic migraine who are on treatment with CGRP and may benefit from additional prevention, it’s suggested to add on oral preventative agents.
• In patients with medication overuse, it’s suggested to use CGRPs before or after withdrawal of acute medications

Based on published data from a 1989 survey the median frequency of migraine attacks is 1.5 per month, and the median duration of an attack is 24 hours; at least 10% of patients have weekly attacks, and 20% have attacks lasting two to three days.(25) Additional surveys from the mid to late 1990’s have confirmed these data.(26-29) Survey results continue to report a median attack duration of 24 hours; 54% to 63% of patients report monthly attacks and 13% to 25% report weekly attacks.(26-29)

1

Amerge Tablets prescribing information. GlaxoSmithKline. October 2020.

2

Almotriptan malate prescribing information. Mylan Pharmaceuticals Inc. May 2017.

3

Frova prescribing information. Endo Pharmaceuticals, Inc. August 2018.

4

Imitrex Injection prescribing information. GlaxoSmithKline. December 2021.

5

Imitrex Nasal Spray prescribing information. GlaxoSmithKline. December 2017.

6

Imitrex Tablets prescribing information. GlaxoSmithKline. September 2020.

7

Maxalt Tablets/Maxalt-MLT Tablets prescribing information. Merck & Co, Inc. December 2020.

8

Onzetra Xsail prescribing information. Avanir Pharmaceuticals. December 2019.

9

Relpax Tablets prescribing information. Pfizer, Inc. March 2020.

10

Sumavel DosePro Prescribing Information. Zogenix, Inc. January 2020.

11

Tosymra prescribing information. Promius Pharma. January 2019.

12

Treximet prescribing information. GlaxoSmithKline. October 2021.

13

Zembrace SymTouch prescribing information. Promius Pharma LLC. June 2019.

14

Zomig Tablets, Zomig-ZMT Orally Disintegrating Tablets prescribing information. AstraZeneca Pharmaceuticals LP. May 2019.

15

Zomig Nasal Spray prescribing information. Amneal Pharmaceuticals. May 2019.

16

Francis GJ, Becker WJ, Prinsheim T. Acute and preventive treatment of cluster headache. Neurology 2010;75:463-473.

17

Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: American Academy of Neurology/American Headache Society. Neurology 2012;78:1337-1345.

18

ICSI. Health care guideline: diagnosis and treatment of headache (updated 2013). https://www.icsi.org/wp-content/uploads/2019/01/HeadacheES.pdf

19

Drugs for migraine. Medical Letter Treatment Guidelines. 2017; 59(1514):27-32.

20

The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. 2015. Available at http://www.headachejournal.org/SpringboardWebApp/userfiles/headache/file/HEAD%20Acute%20Guidelines.pdf.

21

Treatment of cluster headache: the American Headache Society evidence-based guidelines. Headache. 2016 Jul;56(7):1093-106. doi: 10.1111/head.12866.

22

The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. American Headache Society. 12/10/2018. Available at https://onlinelibrary.wiley.com/doi/10.1111/head.13456.

23

Steiner TJ, Jensen R, Katsarava Z, et al. Aids to management of headache disorders in primary care (2nd edition). Journal of Headache and Pain. (2019) 20:57.

24

Sacco S, Bendtsen L, Ashina M, et al. European headache federation guideline on the use of monoclonal antibodies acting on the calcitonin gene related peptide or its receptor for migraine prevention. The Journal of Headache and Pain. (2019) 20:6.

25

Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States: relation to age, income, race and other sociodemographic factors. JAMA 1992;267:64-9.

26

Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646-57.

27

Lipton RB, Scher AI, Kolodner K, et al. Migraine in the United States: epidemiology and patterns of health care use. Neurology. 2002;58:885-94.

28

Steiner TJ, Scher AI, Stewart WF, et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia. 2003;23:519-27.

29

Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States; disability and economic costs. Arch Intern Med. 1999;159:813-8.

30

Ailani J, Burch RC, Robbins MS, on behalf of the Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039.

ALMOTRIPTAN*almotriptan malate tab

12.5 MG ; 6.25 MG

M ; N ; O ; Y

O ; Y

SUMAVEL DOSEPRO*Sumatriptan Succinate Solution Jet-injector 4 MG/0.5ML

M ; N ; O

N

SUMATRIPTAN SUCCINATE*Sumatriptan Succinate Solution Prefilled Syringe 6 MG/0.5ML

6 MG/0.5ML

M ; N ; O ; Y

N

AMERGE*naratriptan hcl tab  ; NARATRIPTAN*naratriptan hcl tab

1 MG ; 2.5 MG

M ; N ; O

O ; Y

FROVA*frovatriptan succinate tab  ; FROVATRIPTAN*frovatriptan succinate tab

2.5 MG

M ; N ; O ; Y

O ; Y

IMITREX*Sumatriptan Succinate Inj 6 MG/0.5ML

6 MG/0.5ML

M ; N ; O

O ; Y

IMITREX*sumatriptan succinate tab  ; SUMATRIPTAN*sumatriptan succinate tab

100 MG ; 25 MG ; 50 MG

M ; N ; O

O ; Y

IMITREX*sumatriptan nasal spray  ; SUMATRIPTAN*sumatriptan nasal spray  ; TOSYMRA*sumatriptan nasal spray

10 MG/ACT ; 20 MG/ACT ; 5 MG/ACT

M ; N ; O

N ; O ; Y

IMITREX STATDOSE REFILL*Sumatriptan Succinate Solution Cartridge 4 MG/0.5ML

4 MG/0.5ML

M ; N ; O

M ; Y

IMITREX STATDOSE REFILL*Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML

6 MG/0.5ML

M ; N ; O

M ; Y

IMITREX STATDOSE SYSTEM*Sumatriptan Succinate Solution Auto-injector 4 MG/0.5ML

4 MG/0.5ML

M ; N ; O

O ; Y

IMITREX STATDOSE SYSTEM*Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML

6 MG/0.5ML

M ; N ; O

O ; Y

MAXALT*rizatriptan benzoate tab  ; RIZATRIPTAN*rizatriptan benzoate tab

10 MG ; 5 MG

M ; N ; O

O ; Y

MAXALT-MLT*rizatriptan benzoate oral disintegrating tab  ; RIZATRIPTAN*rizatriptan benzoate oral disintegrating tab

10  ; 10 MG ; 5 MG

M ; N ; O

O ; Y

ONZETRA XSAIL*Sumatriptan Succinate Exhaler Powder 11 MG/NOSEPIECE

11 MG/NOSEPC

M ; N ; O

N

ELETRIPTAN*eletriptan hydrobromide tab  ; RELPAX*eletriptan hydrobromide tab

20 MG ; 40 MG

M ; N ; O

O ; Y

SUMATRIPTAN/NAPROXEN*sumatriptan-naproxen sodium tab  ; TREXIMET*sumatriptan-naproxen sodium tab

85-500 MG

M ; N ; O

N ; O ; Y

ZEMBRACE SYMTOUCH*Sumatriptan Succinate Solution Auto-injector 3 MG/0.5ML

3 MG/0.5ML

M ; N ; O

N

ZOLMITRIPTAN*zolmitriptan nasal spray  ; ZOMIG*zolmitriptan nasal spray

2.5 MG ; 5 MG

M ; N ; O ; Y

M ; N ; O ; Y

ZOLMITRIPTAN*zolmitriptan tab  ; ZOMIG*zolmitriptan tab

2.5 MG ; 5 MG

M ; N ; O

O ; Y

ZOLMITRIPTAN*zolmitriptan orally disintegrating tab  ; ZOMIG*zolmitriptan orally disintegrating tab

2.5 MG ; 5 MG

M ; N ; O

O ; Y

almotriptan malate tab

12.5 MG ; 6.25 MG

12

Tablets

30

DAYS

Sumatriptan Succinate Solution Prefilled Syringe 6 MG/0.5ML

6 MG/0.5ML

12

Syringes

30

DAYS

Amerge

naratriptan hcl tab

1 MG ; 2.5 MG

18

Tablets

30

DAYS

Frova

frovatriptan succinate tab

2.5 MG

18

Tablets

30

DAYS

Imitrex

Sumatriptan Succinate Inj 6 MG/0.5ML

6 MG/0.5ML

10

Vials

30

DAYS

Imitrex

sumatriptan succinate tab

100 MG ; 25 MG ; 50 MG

18

Tablets

30

DAYS

Imitrex ; Tosymra

sumatriptan nasal spray

10 MG/ACT ; 20 MG/ACT ; 5 MG/ACT

12

Inhalers

30

DAYS

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 4 MG/0.5ML

4 MG/0.5ML

12

Doses

30

DAYS

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML

6 MG/0.5ML

12

Doses

30

DAYS

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 4 MG/0.5ML

4 MG/0.5ML

12

Doses

30

DAYS

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML

6 MG/0.5ML

12

Doses

30

DAYS

Maxalt

rizatriptan benzoate tab

10 MG ; 5 MG

18

Tablets

30

DAYS

Maxalt-mlt

Rizatriptan Benzoate Oral Disintegrating Tab  ; rizatriptan benzoate oral disintegrating tab

10  ; 10 MG ; 5 MG

18

Tablets

30

DAYS

Onzetra xsail

Sumatriptan Succinate Exhaler Powder 11 MG/NOSEPIECE

11 MG/NOSEPC

2

Kits

30

DAYS

Relpax

eletriptan hydrobromide tab

20 MG ; 40 MG

12

Tablets

30

DAYS

Tosymra

Sumatriptan Nasal Spray 10 MG/ACT

10 MG/ACT

18

Doses

30

DAYS

Treximet

sumatriptan-naproxen sodium tab

85-500 MG

18

Tablets

30

DAYS

Zembrace symtouch

Sumatriptan Succinate Solution Auto-injector 3 MG/0.5ML

3 MG/0.5ML

24

Pens

30

DAYS

Zomig

zolmitriptan nasal spray

2.5 MG ; 5 MG

2

Boxes

30

DAYS

Zomig

zolmitriptan tab

2.5 MG ; 5 MG

12

Tablets

30

DAYS

Zomig zmt

zolmitriptan orally disintegrating tab

2.5 MG ; 5 MG

12

Tablets

30

DAYS

almotriptan malate tab

12.5 MG ; 6.25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sumatriptan Succinate Solution Jet-injector 4 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sumatriptan Succinate Solution Prefilled Syringe 6 MG/0.5ML

6 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Amerge

naratriptan hcl tab

1 MG ; 2.5 MG

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Frova

frovatriptan succinate tab

2.5 MG

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Imitrex

Sumatriptan Succinate Inj 6 MG/0.5ML

6 MG/0.5ML

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Imitrex

sumatriptan succinate tab

100 MG ; 25 MG ; 50 MG

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Imitrex ; Tosymra

sumatriptan nasal spray

10 MG/ACT ; 20 MG/ACT ; 5 MG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 4 MG/0.5ML

4 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML

6 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 4 MG/0.5ML

4 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML

6 MG/0.5ML

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Maxalt

rizatriptan benzoate tab

10 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Maxalt-mlt

Rizatriptan Benzoate Oral Disintegrating Tab  ; rizatriptan benzoate oral disintegrating tab

10  ; 10 MG ; 5 MG

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Onzetra xsail

Sumatriptan Succinate Exhaler Powder 11 MG/NOSEPIECE

11 MG/NOSEPC

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Relpax

eletriptan hydrobromide tab

20 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Treximet

sumatriptan-naproxen sodium tab

85-500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zembrace symtouch

Sumatriptan Succinate Solution Auto-injector 3 MG/0.5ML

3 MG/0.5ML

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Zomig

zolmitriptan nasal spray

2.5 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zomig

zolmitriptan tab

2.5 MG ; 5 MG

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Zomig zmt

zolmitriptan orally disintegrating tab

2.5 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

almotriptan malate tab

12.5 MG ; 6.25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sumatriptan Succinate Solution Prefilled Syringe 6 MG/0.5ML

6 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Amerge

naratriptan hcl tab

1 MG ; 2.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Frova

frovatriptan succinate tab

2.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex

Sumatriptan Succinate Inj 6 MG/0.5ML

6 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex

sumatriptan succinate tab

100 MG ; 25 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex ; Tosymra

sumatriptan nasal spray

10 MG/ACT ; 20 MG/ACT ; 5 MG/ACT

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 4 MG/0.5ML

4 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose refill

Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML

6 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 4 MG/0.5ML

4 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imitrex statdose system

Sumatriptan Succinate Solution Auto-injector 6 MG/0.5ML

6 MG/0.5ML

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Maxalt

rizatriptan benzoate tab

10 MG ; 5 MG

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Maxalt-mlt

Rizatriptan Benzoate Oral Disintegrating Tab  ; rizatriptan benzoate oral disintegrating tab

10  ; 10 MG ; 5 MG

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Onzetra xsail

Sumatriptan Succinate Exhaler Powder 11 MG/NOSEPIECE

11 MG/NOSEPC

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Relpax

eletriptan hydrobromide tab

20 MG ; 40 MG

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Tosymra

Sumatriptan Nasal Spray 10 MG/ACT

10 MG/ACT

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Treximet

sumatriptan-naproxen sodium tab

85-500 MG

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Zembrace symtouch

Sumatriptan Succinate Solution Auto-injector 3 MG/0.5ML

3 MG/0.5ML

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Zomig

zolmitriptan nasal spray

2.5 MG ; 5 MG

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Zomig

zolmitriptan tab

2.5 MG ; 5 MG

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Zomig zmt

zolmitriptan orally disintegrating tab

2.5 MG ; 5 MG

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+ - available only as a generic, included as a target in step and quantity limit program
* - available as a generic, included as a target in quantity limit program
^ - available as a generic, included as a target in step and quantity limit program

Target Agent(s) will be approved when ONE of the following is met:

1. The requested agent is eligible for continuation of therapy AND ONE of the following:

1. 1. Information has been provided that indicates the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
   2. The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
2. The patient has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prerequisite agent OR
3. The patient has an FDA labeled contraindication to ALL prerequisite agents

Length of approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

QL

Quantities above the program quantity limit for target agent(s) will be approved when ONE of the following is met:

1. ALL of the following:
   1. The patient has a diagnosis of migraine headache AND
   2. ONE of the following:
      1. The patient is currently using migraine prophylactic medication [i.e., anticonvulsants (i.e., divalproex, valproate, topiramate), beta blockers (i.e., atenolol, metoprolol, nadolol, propranolol, timolol), antidepressants (i.e., amitriptyline, venlafaxine), candesartan, prophylactic use CGRP (i.e., Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Vyepti), onabotulinum toxin A (Botox)] OR
      2. The patient has an intolerance or hypersensitivity to an anticonvulsant, a beta blocker, an antidepressant, candesartan, prophylactic use CGRP, or onabotulinum toxin A listed above OR
      3. The patient has an FDA labeled contraindication to ALL anticonvulsants, beta blockers, antidepressants, candesartan, prophylactic use CGRP, or onabotulinum toxin A listed above AND
   3. Medication overuse headache has been ruled out AND
   4. The patient will NOT be using the requested agent in combination with another acute migraine therapy [e.g., triptan, 5HT-1F (Reyvow), ergotamine, acute use CGRP (e.g., Nurtec, Ubrelvy)] AND
   5. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication OR
2. BOTH of the following:
   1. The patient has a diagnosis of cluster headache AND
   2. The requested agent is an injection or nasal spray

Length of Approval:  12 months

[For a diagnosis of migraine, the quantity requested up to the FDA labeled maximum dose allowed per 24 hours will be approved.]