Antimigraine agents (triptans) prior authorization
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Defines prior authorization requirements, quantity limits, and coverage conditions for triptan migraine and cluster headache therapies in the Georgia Medicaid fee-for-service outpatient pharmacy program. Affects prescribers and pharmacists seeking coverage for listed triptan products.
No material clinical or coverage changes in this revision.
Coverage Criteria for Triptans
Product-specific prior authorization criteria
Approvals require documentation as specified below
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Quantity Level Limit (QLL) criteria
Triptan tablets limited to 9 total tablets per 30 days; exceedance allowed only when specified criteria met
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If a triptan medication is administered in a physician's office or clinic, it must be billed through the DCH physician services program rather than the outpatient pharmacy program. Providers should reference the DCH physician services guidance at www.mmis.georgia.gov for billing instructions and not submit these administrations to the outpatient pharmacy benefit.
Coding and Thresholds
Provider Actions and Documentation Requirements
Prior authorization required; approvals depend on documented trials/LOMN
Prior authorization is required for the listed non-preferred oral triptans and certain non-oral formulations; approvals are granted only when the prescriber documents prior trial and failure/intolerance/allergy/contraindication or drug interaction with the specified preferred agents, and for some formulations a letter of medical necessity or explanation why oral products cannot be used.
- Non-preferred oral triptans (almotriptan, eletriptan, frovatriptan, naratriptan, zolmitriptan) approvable only after trials/failures of rizatriptan (tablet/ODT) and sumatriptan tablets.
- Onzetra Xsail, Tosymra, sumatriptan injection require explanation why oral products are not appropriate; additional failure documentation required for nasal products.
- Treximet and Zembrace SymTouch require a written letter of medical necessity (LOMN) as specified below.
Step therapy: trial of both preferred triptans required
Non-preferred oral triptans (almotriptan, eletriptan, frovatriptan, naratriptan, zolmitriptan) require documentation of trials and failure/intolerance/allergy/contraindication or drug interaction to both preferred products (rizatriptan tablet/ODT and sumatriptan tablets) before approval.
- Provider must document ineffectiveness, allergy, contraindication, drug-to-drug interaction, or intolerable side effects to rizatriptan and sumatriptan tablets.
Treximet requires written LOMN
Prescriber must submit a written letter of medical necessity explaining why generic sumatriptan and generic naproxen as separate products are not appropriate for the member to support Treximet coverage.
- LOMN must state specific reasons the preferred separate products are inappropriate for this patient.
Zembrace SymTouch requires written LOMN and oral-avoidance justification
For Zembrace SymTouch the prescriber must explain why the member is unable to take oral products and submit a written letter of medical necessity stating why generic sumatriptan injection is not appropriate.
- LOMN must justify why generic sumatriptan injection cannot be used and include inability to use oral therapy.
Onzetra/Tosymra: document inability to take oral products and prior nasal failures
For Onzetra Xsail and Tosymra the prescriber must explain why the member is unable to take oral products and document prior ineffectiveness/allergy/contraindication/drug interaction or intolerable side effects to the specified nasal and sumatriptan nasal products.
- Member must have failed or been intolerant/allergic/contraindicated to Zomig Nasal Spray and to sumatriptan nasal spray as described in the policy.
- Prescriber explanation must explicitly state why oral products are not appropriate for the member.
Denial risk: missing trials/failure documentation for preferred agents
Coverage for non-preferred triptans will be denied if the provider fails to document trials and documented ineffectiveness, allergy, contraindication, drug interaction, or intolerable side effects to the two preferred products.
- Ensure documentation shows trials of rizatriptan (tablet/ODT) and sumatriptan tablets with outcomes (ineffective, intolerable, allergic, contraindicated, or drug interaction).
Denial risk: missing justification for non-oral therapy / missing LOMN
For non-oral formulations (nasal, injection, Xsail/Tosymra), the prescriber must explain why the member is unable to take oral products and provide a letter of medical necessity when required; lack of this justification may result in denial.
- Sumatriptan injection and Onzetra/Tosymra require explanation of inability to take oral therapy.
- Zembrace SymTouch additionally requires a written LOMN explaining why generic sumatriptan injection is not appropriate.
Background
Triptans are acute therapies used for migraine treatment and, for some injectable products, for cluster headache. Multiple formulations are available (oral tablets, orally disintegrating tablets, nasal, nasal powder, and injection), and non‑oral formulations are indicated when a patient cannot use oral medications. Prior authorization requirements and quantity limits are applied to ensure preferred, cost‑effective therapies are tried first and to document medical necessity for non‑preferred or non‑oral formulations.
Definitions
Initial Therapy Requirements
Initial therapy requirements
Initial coverage rules for specific agents
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Continuation / Renewal Criteria
Continuation/renewal
Renewal/continuation
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Step Therapy Requirements
| Step | Required documentation/prior trial(s) |
|---|---|
| 1 | Documentation of ineffectiveness, allergy, contraindication, drug–drug interaction, or intolerable side effect to BOTH preferred products: rizatriptan (tablet or ODT) and sumatriptan (tablet). |
Quantity Limits
Site of Care Billing
Office-administered medications: bill through DCH physician services program
Medications administered in a physician's office or clinic must be billed through the DCH physician services program and not the outpatient pharmacy benefit.
- See MMIS Georgia for physician services billing information (www.mmis.georgia.gov).
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