zolmitriptan ODT — CareFirst (Caremark)

Initial criteria

• For cluster headache: ALL of the following must be met:
• • Patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease OR uncontrolled hypertension
• • 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)
• • ONE of the following:
• – Requested drug is NOT being used concurrently with another triptan 5‑HT1 agonist
• – Requested drug is being used concurrently with another triptan 5‑HT1 agonist AND patient requires more than one triptan due to clinical need for differing routes of administration
• For migraine headache: ALL of the following must be met:
• • Patient does NOT have confirmed or suspected cardiovascular OR cerebrovascular disease OR uncontrolled hypertension
• • Medication overuse headache has been considered AND ruled out
• • ONE of the following:
• – 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)
• – Patient is unable to take migraine prophylactic therapies due to inadequate response, intolerance, or contraindication (same examples apply)
• • ONE of the following:
• – Requested drug is NOT being used concurrently with another triptan 5‑HT1 agonist
• – Requested drug is being used concurrently with another triptan 5‑HT1 agonist AND patient requires more than one triptan due to clinical need for differing routes of administration

Approval duration

12 months (MMT 903‑J) or 36 months (1‑J)