Product Details

Mint-Zolmitriptan

Zolmitriptan
2.5 mg
Tablet

DIN/PIN/NPN

02419521

Manufacturer

Mint Pharmaceuticals Inc.

Formulary Listing Date

2014-05-29

Unit Price

6.8583

Amount MOH Pays

6.8583

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

N02CC03

Interchangeable Products

DIN/ PIN/ NPN	Brand name	Unit Price	Amount MOH pays
02238660	Zomig	16.9773	6.8633
02442655	Zolmitriptan	6.8583	6.8583
02313960	Teva-Zolmitriptan	6.8583	6.8583
02362988	Sandoz Zolmitriptan	6.8586	6.8586
02324229	PMS-Zolmitriptan	6.8586	6.8586
02421534	Nat-Zolmitriptan	6.8633	6.8633
02419521	Mint-Zolmitriptan	6.8583	6.8583
02399458	Mar-Zolmitriptan	6.8583	6.8583
02421623	Jamp-Zolmitriptan	6.8583	6.8583
02477106	Jamp Zolmitriptan	6.8583	6.8583
02458780	CCP-Zolmitriptan	6.8586	6.8586
02481030	Auro-Zolmitriptan	6.8633	6.8633
02380951	Apo-Zolmitriptan	6.8583	6.8583
02489392	NRA-Zolmitriptan	6.8600	6.8600

LU Clinical Criteria

NO

EAP Criteria

Therapeutic Class	Reimbursement Criteria
Migraine Drugs	Zolmitriptan Brand(s): Zomig Dosage Form/Strength: 2.5 mg tablet Brand(s): Zomig Rapimelt Dosage Form/Strength: 2.5 mg dispersible tablet For the treatment of migraines with or without aura in patients who have failed an adequate trial of or experienced intolerance to all other oral triptans considered under the Exceptional Access Program. Duration of Approvals: 5 years Renewal requests may be considered for patients who continue to benefit from treatment. The physician must provide the frequency of triptan use. EAP Drug Request Form: Standard Form for EAP Drug Requests

Product Monograph