Triptans (5-HT1 Receptor Agonist) – Net Results

Restricted Product(s)

• Sumatriptan succinate (sumatriptan succinate solution prefilled syringe 6 Mg/0.5ml)

FDA Approved Use

• For acute treatment of migraine with or without aura in adults.

Criteria for Approval of Restricted Product(s)

1. The patient has tried and failed TWO unrestricted triptan products; OR 
2. The patient has a clinical intolerance/contraindication to all unrestricted triptan products on the formulary that have not been tried; AND 
3. For products that require Value PA, refer to the Value PA UM Criteria.

Duration of Approval: 365 days (1 year) 

Quantity Limitations

quantity limitations apply to brand and associated generic products. 

Quantity Limit Exception Criteria

1. Patient has tried and failed at least two of the following abortive migraine therapy medication classes: 
   1. NSAIDS/COX-2 Inhibitor (Ex. ibuprofen, naproxen, diclofenac, celecoxib, etc.) 
   2. Acetaminophen (Tylenol) 
   3. Ergotamine-containing products (Ex. Cafergot, Ergomar, etc.); AND
2. If the patient experiences > 4 migraine headaches per month, prophylactic therapy (Ex. amitriptyline, nortriptyline, topiramate, propranolol, divalproex) should have been given an adequate trial of at least 2 – 3 months; AND 
3. The possibility of medication-induced, rebound or chronic daily headache has been considered and ruled out; AND 
4. The requested triptan is not used in combination with another triptan product or an ergotamine product due to the possibility of increased blood pressure effect; AND 
5. The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR 
6. If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed). 

Duration of Approval: 365 days (1 year)

References

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.

November 2023: Criteria update: Updated terminology from Medical Necessity PA to Value PA.

August 2023: Criteria update: Removed almotriptan, Amerge, Frova, frovatriptan, Imitrex, Maxalt, Maxalt MLT, Ozentra, Relpax, Sumatriptan/Naproxen, Sumavel Dose Pro, Tosymra, Treximet, Zecuity, Zembrance, Zolmitriptan Nasal Spray, Zomig Spray, Zomig, Zomig ZMT from restricted products.

April 2023: Criteria update: Updated to reflect multisource code change to Zomig nasal spray 2.5mg.

Nov 2021: Criteria change: Changed duration of approval from 1095 days to 365 days.

Feb 2021: Criteria change: Annual Criteria Review. Added authorized generic for Zomig (zolmitripan nasal spray) to the policy; Removed discontinued products from policy - Brand Alsuma, Brand Axert; Require t/f of generic equivalent of branded medication; Removed NF statement.

Oct 2019: Criteria update: Corrected QL for Ozetra to 48 doses.

Sept 2019: Criteria update: Tosymra added to the policy

Apr 2019: Added almotriptan and frovatriptan to restricted products (still excluded from formulary) and eletriptan added as an alternative.

Apr 2018: Removed amlotriptan and frovatriptan from suggested alternatives due to formualry exclusion.

Nov 2017: Reformatted; added new to market, single source (MSC M), sumatriptan/naproxen to restrictions; removed reference to Midrin as it is no longer on the market.

Sep 2016: Reviewed for Net Results Formulary; non-formulary verbiage added. Added new to market strength of Treximet (10mg /60mg)

May 2016: Updated to reflect multisource code changes to generic sumatriptan prefilled syringe and nasal spray

Apr 2016: Added new to market drug Onzetra Xsail

Mar 2016: Added new to market drug Zembrace Symtouch

Jan 2016: Updated Triptan Program to apply step therapy to all brand formulations of triptans. Quantity Limits were updated.