Product Details

Almotriptan

Almotriptan
12.5 mg
Tablet


DIN/PIN/NPN

02466821

Manufacturer

Sanis Health Inc.

Formulary Listing Date

2020-06-30  

Unit Price

9.7833

Amount MOH Pays

9.7833

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N02CC05

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02434849 Teva-Almotriptan 9.7833 9.7833
02405334 Sandoz Almotriptan 9.7825 9.7825
02398443 Mylan-Almotriptan 9.7833 9.7833
02248129 Axert NA NA
02405806 Apo-Almotriptan 9.7833 9.7833
02466821 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

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