sumatriptan injection — CareFirst (Caremark)

Initial criteria

• 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)
• 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