Product Details

Axert

Almotriptan
6.25 mg
Tablet

DIN/PIN/NPN

02248128

Manufacturer

Janssen-Ortho Inc.

Formulary Listing Date

2013-09-27

Unit Price

NA

Amount MOH Pays

NA

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

28:92:00 Miscellaneous Central Nervous System Drugs

Therapeutic Note

NO

ATC Code

N02CC05

Interchangeable Products

DIN/ PIN/ NPN	Brand name	Unit Price	Amount MOH pays
02398435	Mylan-Almotriptan	9.7833	9.7833
02248128	Axert	NA	NA
02405792	Apo-Almotriptan	9.7833	9.7833

LU Clinical Criteria

NO

EAP Criteria

Therapeutic Class	Reimbursement Criteria
Migraine Drugs	Almotriptan Brand(s): Axert Dosage Form/Strength: 6 mg, 12.5mg tablet Naratriptan Brand(s): Amerge Dosage Form/Strength: 1 mg, 2.5 mg tablet Rizatriptan Brand(s): Maxalt, Maxalt RPD Dosage Form/Strength: 5 mg, 10 mg tablet and wafer Sumatriptan Brand(s): Imitrex Dosage Form/Strength: 50 mg, 100 mg tablet For the treatment of migraines with or without aura in patients who failed adequate trials of other medications for migraines (e.g., acetaminophen, NSAIDs) and where the following information is provided: Details of migraine prophylactic regimens (e.g., amitriptyline, beta-blockers) tried or rationale why they are inappropriate; AND The number of attacks, duration, and severity of migraines. Duration of Approval: 5 years Renewal requests may be considered for patients who continue to benefit from treatment. The physician must provide the frequency of triptan use. Warning: The frequent use of triptans (i.e., more than three days per week for longer than three months at a time) may predispose a patient to developing triptan-induced chronic daily headaches. EAP Drug Request Form: Standard Form for EAP Drug Requests

Product Monograph