Product Details
Imitrex
Sumatriptan Succinate6 mg/0.5 mL
Solution for Injection
0.5-mL Prefilled Syringe Pack
DIN/PIN/NPN
02212188
Manufacturer
Glaxo Wellcome Inc.
Formulary Listing Date
2013-04-30
Unit Price
49.9600
Amount MOH Pays
36.5888
Coverage Status
Off-Formulary Interchangeable Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N02CC01
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02361698 | Taro-Sumatriptan | 36.5888 | 36.5888 |
02212188 | Imitrex | 49.9600 | 36.5888 |
LU Clinical Criteria
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Migraine Drugs | Almotriptan
Naratriptan
Rizatriptan
Sumatriptan
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:
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: |
Migraine Drugs | Sumatriptan
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 has documented intolerance* to an oral triptan. The following information must also be provided:
*The nature of intolerance or why oral sumatriptan cannot be used must be specified. Duration of Approval: 5 years Renewal requests for sumatriptan 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: |