Imitrex Injection — CareFirst (Caremark)

Initial criteria

• 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 inadequate treatment response, intolerance, or contraindication [same examples]
• 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