eletriptan — CareFirst (Caremark)

Preferred products

• sumatriptan injection
• sumatriptan nasal spray
• zolmitriptan nasal spray

Initial criteria

• For cluster headache: Authorization may be granted when ALL of the following criteria are met: the patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease OR uncontrolled hypertension; the request is for sumatriptan injection, sumatriptan nasal spray, OR zolmitriptan nasal spray (e.g., Imitrex Injection, Imitrex Nasal Spray, Onzetra Xsail, Tosymra, Zomig Nasal Spray); AND the patient meets ONE of the following: the requested drug is NOT being used concurrently with another triptan 5‑HT1 agonist OR the requested drug is being used concurrently with another triptan 5‑HT1 agonist AND the patient requires more than one triptan 5‑HT1 agonist due to clinical need for differing routes of administration.
• For migraine headache: Authorization may be granted when ALL of the following criteria are met: the patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease OR uncontrolled hypertension; medication overuse headache has been considered AND ruled out; the patient meets ONE of the following: the patient is currently using migraine prophylactic therapy (examples: divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, venlafaxine, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant) OR the patient is unable to take migraine prophylactic therapies due to an inadequate treatment response, intolerance or contraindication; AND the patient meets ONE of the following: the requested drug is NOT being used concurrently with another triptan 5‑HT1 agonist OR the requested drug is being used concurrently with another triptan 5‑HT1 agonist AND the patient requires more than one triptan 5‑HT1 agonist due to clinical need for differing routes of administration.

Approval duration

12 months (MMT 903-J) or 36 months (J)