Product Details

Mylan-Rizatriptan ODT

Rizatriptan
5 mg
Orally Disintegrating Tablet


DIN/PIN/NPN

02379198

Manufacturer

Mylan Pharmaceuticals ULC

Formulary Listing Date

2012-03-26  

Unit Price

11.1150

Amount MOH Pays

11.1150

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N02CC04

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02396661 Teva-Rizatriptan ODT 11.1150 11.1150
02351870 Sandoz Rizatriptan ODT 11.1150 11.1150
02446111 Rizatriptan ODT 11.1150 11.1150
02442906 Rizatriptan ODT 11.1150 11.1150
02393360 PMS-Rizatriptan RDT 11.1150 11.1150
02436604 Nat-Rizatriptan ODT 11.1650 11.1650
02379198 Mylan-Rizatriptan ODT 11.1150 11.1150
02439573 Mint-Rizatriptan ODT 11.1150 11.1150
02240518 Maxalt RPD 21.4865 11.1650
02462788 Mar-Rizatriptan ODT 11.1150 11.1150
02465086 Jamp-Rizatriptan ODT 11.1150 11.1150
02374730 Co Rizatriptan ODT 11.1150 11.1150
02458764 CCP-Rizatriptan 11.1150 11.1150
02393484 Apo-Rizatriptan RPD 11.1150 11.1150
02483270 Accel-Rizatriptan ODT 7.7800 7.7800
 

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

View Monograph