Triptan quantity limits

Drug - Triptans

December 2007

Therapeutic area - Migraine Headache

Table 1. Oral and Nasal Dosage Forms

Brand	Generic	Form	Strengths
Amerge	naratriptan	Tablet	1 mg, 2.5 mg
Axert	almotriptan	Tablet	6.25 mg, 12.5 mg
Frova	frovatriptan	Tablet	2.5 mg
Imitrex	sumatriptan	Tablet	25 mg, 50 mg, 100 mg
Imitrex	sumatriptan	Nasal spray	5 mg, 20 mg
Maxalt Maxalt MLT	rizatriptan	Tablet Dissolving tablet	5 mg, 10 mg
Relpax	eletriptan	Tablet	20 mg, 40 mg
Zomig Zomig ZMT	zolmitriptan	Tablet Dissolving tablet	2.5 mg, 5 mg
Zomig	zolmitriptan	Nasal spray	5 mg

Table 2. Injectable dosage forms

Brand	Generic	Form	Strengths
Imitrex	sumatriptan	Injection kit	6 mg/0.5mL, 4 mg/0.5mL
Imitrex	sumatriptan	Kit refill	6 mg/0.5mL
Imitrex	sumatriptan	Vials for injection	6 mg/0.5mL

Oral and Nasal dosage forms

Quantity limits will be 18 oral or nasal dosage forms of all triptan brands per rolling calendar month.

Imitrex injectable

Imitrex injectable quantity limits: 2 kits in 15 days. The minimum quantity is set to 1 kit and the maximum quantity is set to 2 kits.

Criteria for QL override

One time override per 12 months for the purpose of minimizing Emergency Department visits, unless patient has cluster headache. If patient has cluster headache, more fills may be needed (see below) AND
The triptan is being prescribed by a headache specialist or patient has an appointment to see a headache specialist OR
Provider is able to demonstrate on behalf of the client that the excess quantity requested has resulted in a decrease in ER visits or hospitalization due to headache or migraine disorder OR
Prescriber provides peer reviewed literature showing efficacy and safety of dose that exceeds manufacturer's recommended dosage

For Cluster Headache Only
Cluster headache must be confirmed. Patient must receive relief of cluster headache pain from the triptan. A PA may be issued for the amount of drug necessary to cover the cluster headache episode.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411