Product Details

Imitrex DF

Sumatriptan Succinate
50 mg
Tablet


DIN/PIN/NPN

02212153

Manufacturer

GlaxoSmithKline Inc., GlaxoSmithKline Consumer Health Care

Formulary Listing Date

2007-06-06  

Unit Price

18.6967

Amount MOH Pays

9.0650

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
02286823 Teva-Sumatriptan DF 9.0650 9.0650
02385570 Sumatriptan DF 9.0650 9.0650
02212153 Imitrex DF 18.6967 9.0650
 

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
Migraine Drugs

Sumatriptan

  • Brand(s): Imitrex Injection
  • Dosage Form/Strength: 12 mg/mL subcutaneous injection

  • Brand(s): Imitrex Nasal Spray
  • Dosage Form/Strength: 5 mg/dose and 20 mg/dose nasal spray

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: 

  • 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. 

*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:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph