Zembrace SymTouch (sumatriptan injection) — Medical Mutual

Preferred products

• rizatriptan (tablets and orally disintegrating tablets)
• sumatriptan (tablets, nasal spray, injection)

Initial criteria

• If the patient has tried one Step 1 product, authorization for a Step 2 product may be given.
• If the patient has tried two, in any combination, Step 1 or Step 2 products, authorization for a Step 3 product may be given.
• Step Therapy Exception Criteria: Approve for 1 year if the patient meets ONE of the following:
• A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents [documentation required]; OR
• B. The patient has a contraindication to all preferred agents [documentation required]; OR
• C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days [verification in prescription claims history required] AND meets ONE of the following:
• 1. The patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred product (AA-rated or AB-rated); OR
• 2. When 130 days of the patient’s prescription claims history is unavailable, the prescriber must verify that the patient has been receiving the requested non-preferred agent for 90 days via paid claims AND there is no generic equivalent available for the requested nonpreferred product (AA-rated or AB-rated).

Reauthorization criteria

• All approvals for continuation of therapy are provided for 1 year unless noted otherwise.

Approval duration

1 year