Imitrex Injection (sumatriptan) — CareFirst (Caremark)

Initial criteria

• Cluster headache: The patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease, OR uncontrolled hypertension
• Cluster headache: 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)
• Cluster headache: The patient meets ONE of the following: (1) The requested drug is NOT being used concurrently with another triptan 5-HT1 agonist OR (2) 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
• Migraine headache: The patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease, OR uncontrolled hypertension
• Migraine headache: Medication overuse headache has been considered AND ruled out
• Migraine headache: The patient meets ONE of the following: (1) The patient is currently using migraine prophylactic therapy OR (2) The patient is unable to take migraine prophylactic therapies due to an inadequate treatment response, intolerance or contraindication [Examples include divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, venlafaxine, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant]
• Migraine headache: The patient meets ONE of the following: (1) The requested drug is NOT being used concurrently with another triptan 5-HT1 agonist OR (2) The requested drug is being used concurrently with another triptan 5-HT1 agonist AND the patient requires more than one due to clinical need for differing routes of administration

Approval duration

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