CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

PRIOR AUTHORIZATION CRITERIA

Prior authorization criteria, quantity limits, duration of approval, and coverage conditions for 5-HT1 agonist drugs (multiple brand/generic triptans, all dosage forms) per CVS Caremark post-limit PA policy as adopted by Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPRIOR AUTHORIZATION CRITERIA

Policy CodePolicy N/A

Change TypeClarified document references; no material clinical changes

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization and document that the patient meets all PA criteria, including cardiovascular risk assessment, appropriate diagnosis, prophylactic therapy use or documented inability to use prophylaxis, and that medication overuse headache has been considered and ruled out when applicable.

POLICY UPDATE CHANGES

20+Referenced branded/generic products

MultipleFormulations

25/751-month/3-month supply window used for limits

12/36mDuration of Approval options

Coverage Summary

This is a CVS Caremark post-limit Prior Authorization (Post Limit PA) policy adopted by Neighborhood Health Plan of Rhode Island for 5-HT1 agonists (triptans) covering acute migraine and select cluster headache indications. The policy lists multiple branded and generic triptan products and formulations and summarizes FDA indications and limitations of use for those products. It establishes clinical PA requirements and product-specific quantity limits (per-product maximums and 1-month/3-month windows) that apply after standard quantity limits are exceeded.

Key policy thresholds & duration

Quantity limitsVaries by product and strength — product-specific 1-month and 3-month limits are listed (examples: almotriptan 18 tablets/25 days & 54/75 days; frovatriptan 27/25 days & 81/75 days; sumatriptan injection vials 18 vials/25 days & 55/75 days)

1-month / 3-month windowPolicy uses 25 days for a 30-day fill and 75 days for a 90-day fill to define 1-month and 3-month limits

Per‑day maximum dosingDaily max doses vary by formulation (examples: most oral tablets max 2/day; rizatriptan up to 3/day; some injections up to 2–4/day depending on product)

Duration of approval (DOA)Two DOA options specified: MMT 903-J = 12 months; 1-J = 36 months

Referenced product countPolicy lists 20+ branded and generic triptan products and multiple formulations (tablet, nasal, injection, film, autoinjector)

Primary Prior Authorization Criteria

The requested drug will be covered with prior authorization when the following criteria are met:

Screening: The patient does not have confirmed or suspected cardiovascular or cerebrovascular disease, or uncontrolled hypertension
Indication and prophylaxis options
- Option A: Patient has a diagnosis of migraine headache; patient is currently using migraine prophylactic therapy; medication overuse headache has been considered and ruled out
  Examples of prophylactic therapy: divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, amitriptyline, venlafaxine
- Option B: Patient has a diagnosis of migraine headache; patient is unable to take migraine prophylactic therapies due to inadequate treatment response, intolerance or contraindication; medication overuse headache has been considered and ruled out
  Examples of prophylactic therapy: divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, amitriptyline, venlafaxine
- Cluster headache indication: The request is for sumatriptan injection, sumatriptan nasal spray, or zolmitriptan nasal spray for the treatment of cluster headache
  Examples: Imitrex Injection, Imitrex Nasal Spray, Onzetra Xsail, Tosymra, Zomig Nasal Spray
Concurrent use rules
- No concurrent triptan: The requested drug is not being used concurrently with another triptan 5-HT1 agonist
- Concurrent use allowed: 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

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Provider Actions & Requirements

Prior Authorization

Prior authorization required

Providers must obtain prior authorization and document that the patient meets all PA criteria: no confirmed or suspected cardiovascular or cerebrovascular disease or uncontrolled hypertension; an appropriate diagnosis of migraine headache (or cluster headache when applicable); for migraine either current use of migraine prophylactic therapy or inability to take prophylaxis due to inadequate response, intolerance, or contraindication; medication overuse headache has been considered and ruled out when applicable; and concurrent use of another triptan is allowed only if there is documented clinical need for differing routes of administration.

No confirmed or suspected cardiovascular or cerebrovascular disease, or uncontrolled hypertension
Appropriate diagnosis: migraine headache (or cluster headache for specified formulations)
Document current migraine prophylactic therapy OR documented inadequate response, intolerance, or contraindication to prophylactic agents
Medication overuse headache considered and ruled out when applicable
Concurrent triptan use only if clinical need for differing routes is documented

Documentation Required

Document prophylactic therapy or contraindication

When requesting approval under the migraine criteria, document either the patient’s current use of migraine prophylactic therapy or documentation that the patient is unable to take prophylactic therapies due to inadequate treatment response, intolerance, or contraindication. Examples of prophylactic agents listed in the policy include divalproex sodium, topiramate, valproate sodium, metoprolol, propranolol, timolol, atenolol, nadolol, amitriptyline, and venlafaxine.

Document current use of migraine prophylactic therapy
Or document inadequate response, intolerance, or contraindication to prophylactic agents
Examples: divalproex sodium; topiramate; valproate sodium; metoprolol; propranolol; timolol; atenolol; nadolol; amitriptyline; venlafaxine

Billing Rule

Quantity limits enforce dispensing

Dispensing pharmacies may fill quantities per manufacturer package size up to the posted quantity limits. Fills must respect the policy’s 1-month (25-day) and 3-month (75-day) quantity limits (examples and product-specific limits provided in the policy).

Pharmacy may use manufacturer package size when filling up to the quantity limit
Respect 1-month (25-day) and 3-month (75-day) limits

Denial Risk

Concurrent triptan use restriction

Requests will be denied if the requested triptan is being used concurrently with another triptan 5-HT1 agonist unless there is documentation that the patient requires more than one triptan due to clinical need for differing routes of administration.

Concurrent triptan use is not permitted without documentation of clinical need for differing routes

Applicable Products and Quantity Limits

Drugs / branded and generic referencedmixed

almotriptan	Almotriptan (various strengths/tablets)
naratriptan	Amerge (naratriptan)
frovatriptan	Frova (frovatriptan)
sumatriptan_injection	Imitrex Injection / Zembrace SymTouch (sumatriptan injections/auto-injectors)
sumatriptan_nasal	Imitrex Nasal Spray, Onzetra Xsail, Tosymra (sumatriptan nasal/inhalation formulations)
sumatriptan_tablets	Imitrex Tablets (sumatriptan tablets)
rizatriptan	Maxalt / Maxalt-MLT / RizaFilm (rizatriptan tablets/films)
eletriptan	Relpax (eletriptan)
zolmitriptan	Zomig / Zomig-ZMT (zolmitriptan nasal/tablet)
treximet	Treximet (sumatriptan/naproxen)

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Quantity limit guidance by product/strength/formmixedCovered

almotriptan_6.25mg	Max 2 tablets/24h; 1 month = 18 tablets / 25 days; 3 month = 54 tablets / 75 days
almotriptan_12.5mg	Max 2 tablets/24h; 1 month = 18 tablets / 25 days; 3 month = 54 tablets / 75 days
naratriptan_1mg	Max 2 tablets/24h; 1 month = 18 tablets / 25 days; 3 month = 54 tablets / 75 days
naratriptan_2.5mg	Max 2 tablets/24h; 1 month = 18 tablets / 25 days; 3 month = 54 tablets / 75 days
frovatriptan_2.5mg	Max 3 tablets/24h; 1 month = 27 tablets / 25 days; 3 month = 81 tablets / 75 days
sumatriptan_injection_6mg_vial	Max 2 injections/24h (12 mg); 1 month = 18 vials (9 mL) / 25 days; 3 month = 55 vials (27.5 mL) / 75 days
sumatriptan_injection_statdose_4mg_syringe	Max 3 injections/24h (12 mg); 1 month = 27 syringes (13.5 mL) / 25 days; 3 month = 81 syringes (40.5 mL) / 75 days
sumatriptan_injection_statdose_6mg_syringe	Max 2 injections/24h (12 mg); 1 month = 18 syringes (9 mL) / 25 days; 3 month = 54 syringes (27 mL) / 75 days
sumatriptan_nasal_5mg	Max 4 sprays/24h; 1 month = 36 units / 25 days; 3 month = 108 units / 75 days
sumatriptan_nasal_20mg	Max 2 sprays/24h; 1 month = 18 units / 25 days; 3 month = 54 units / 75 days

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Quantity limits are expressed as a maximum allowed per 24 hours and are translated into a 1-month (25-day) and 3-month (75-day) window for dispensing as specified in the policy code table; dispensing pharmacies may fill to manufacturer package sizes up to these posted quantity limits.

Clinical Evidence / Rationale

FDA indications: triptans are indicated for the acute treatment of migraine attacks (many products are indicated for adults, with some approved for adolescents or pediatric age groups) and selected products (for example, sumatriptan injection and certain nasal formulations) are indicated for acute cluster headache. Limitations of use noted in product labeling include use only where a clear diagnosis of migraine or cluster headache has been established, lack of indication for migraine prevention, and reevaluation of diagnosis if there is no response to the first treated attack. The policy’s rationale for PA and product-specific quantity limits is to ensure appropriate, evidence-aligned use (acute treatment only, not prevention), to mitigate risk (including medication overuse headache and cardiovascular/cerebrovascular safety concerns), and to align dispensing with manufacturer package sizes and predefined per-24-hour and 1-month/3-month quantity limits.