Division: Pharmacy Services
Subject: Prior Authorization Criteria
Original Development Date:
Original Effective Date:
Revision Date:
May 7, 2012, June 23, 2015
ANTIMIGRAINE AGENTS (TRIPTANS)
Length of Authorization: Up to one year
1. Is there any reason the patient cannot be changed to a preferred medication? Acceptable reasons
include:
a. Allergy to preferred medications
b. Contraindication to preferred medications
c. History of serious reaction (eg. anaphylaxis, seizure . . .) to preferred medications
2. Has the patient failed therapeutic trials with all preferred medications? If so, documentation must be
provided.
Drug Name
Quantity Limit (# / 30days)
Directives
Treximet (sumatriptan/naproxen)
9/30

Amerge (narariptan)
Frova (frovatriptan)
Zomig (zolmitriptan)
Relpax (eletriptan)
Axert (almotritan)
9/30
9/30
6/30
6/30
6/30

Refer requests to the individual
ingredients (sumatriptan and
naproxen).
Refer requests for these drugs to the
preferred alternatives (sumatriptan
and rizatriptan)
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