Triptans, Oral

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
naratriptan HCl AMERGE TABLET Y Quantity Limit  
naratriptan HCl NARATRIPTAN HCL TABLET Y Quantity Limit  
sumatriptan succinate IMITREX TABLET Y Quantity Limit  
sumatriptan succinate SUMATRIPTAN SUCCINATE TABLET Y Quantity Limit  
almotriptan malate ALMOTRIPTAN MALATE TABLET N Quantity Limit  
almotriptan malate AXERT TABLET N Quantity Limit  
eletriptan hydrobromide RELPAX TABLET N Quantity Limit  
eletriptan hydrobromide ELETRIPTAN HBR TABLET N Quantity Limit  
frovatriptan succinate FROVA TABLET N Quantity Limit  
frovatriptan succinate FROVATRIPTAN SUCCINATE TABLET N Quantity Limit  
rizatriptan benzoate RIZATRIPTAN TAB RAPDIS N Quantity Limit  
rizatriptan benzoate MAXALT MLT TAB RAPDIS N Quantity Limit  
rizatriptan benzoate MAXALT TABLET N Quantity Limit  
rizatriptan benzoate RIZATRIPTAN TABLET N Quantity Limit  
sumatriptan succ/naproxen sod TREXIMET TABLET N Quantity Limit  
zolmitriptan ZOLMITRIPTAN ODT TAB RAPDIS N Quantity Limit  
zolmitriptan ZOMIG ZMT TAB RAPDIS N Quantity Limit  
zolmitriptan ZOLMITRIPTAN TABLET N Quantity Limit  
zolmitriptan ZOMIG TABLET N Quantity Limit