Product Details

Jamp-Rizatriptan IR

Rizatriptan
10 mg
Tablet


DIN/PIN/NPN

02429241

Manufacturer

Jamp Pharma Corporation

Formulary Listing Date

2015-01-28  

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
02516756 Rizatriptan 11.1150 11.1150
02240521 Maxalt 21.4865 11.1150
02379678 Mar-Rizatriptan 11.1150 11.1150
02429241 Jamp-Rizatriptan IR 11.1150 11.1150
02380463 Jamp-Rizatriptan 11.1150 11.1150
02381702 Act Rizatriptan 11.1150 11.1150
02441144 Auro-Rizatriptan 11.1150 11.1150
02393476 Apo-Rizatriptan 11.1150 11.1150
 

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