Product Details

Accel-Rizatriptan ODT

Rizatriptan
10 mg
Orally Disintegrating Tablet


DIN/PIN/NPN

02483289

Manufacturer

Accel Pharma Inc.

Formulary Listing Date

2020-01-31  

Unit Price

7.7800

Amount MOH Pays

7.7800

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
02396688 Teva-Rizatriptan ODT 11.1150 11.1150
02351889 Sandoz Rizatriptan ODT 11.1150 11.1150
02446138 Rizatriptan ODT 11.1150 11.1150
02442914 Rizatriptan ODT 11.1150 11.1150
02393379 PMS-Rizatriptan RDT 11.1150 11.1150
02436612 Nat-Rizatriptan ODT 11.1650 11.1650
02379201 Mylan-Rizatriptan ODT 11.1150 11.1150
02439581 Mint-Rizatriptan ODT 11.1150 11.1150
02240519 Maxalt RPD 21.4865 11.1650
02462796 Mar-Rizatriptan ODT 11.1150 11.1150
02465094 Jamp-Rizatriptan ODT 11.1150 11.1150
02374749 Co Rizatriptan ODT 11.1150 11.1150
02458772 CCP-Rizatriptan 11.1150 11.1150
02393492 Apo-Rizatriptan RPD 11.1150 11.1150
02492490 AG-Rizatriptan ODT 11.1150 11.1150
02483289 Accel-Rizatriptan ODT 7.7800 7.7800
02489384 NRA-Rizatriptan ODT 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