rizatriptan (Maxalt, Maxalt-MLT, RizaFilm) — CareFirst (Caremark)
migraine headache
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 [NOTE: Examples of prophylactic therapy are divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, venlafaxine, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant]
- • The patient is unable to take migraine prophylactic therapies due to an inadequate treatment response, intolerance or contraindication [NOTE: Examples of prophylactic therapy are divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, venlafaxine, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant]
- The patient meets ONE of the following:
- • The requested drug is NOT being used concurrently with another triptan 5-HT1 agonist
- • 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)