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 AXERT TABLET N Quantity Limit  
ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE TABLET N Quantity Limit  
ELETRIPTAN HBR RELPAX TABLET N Quantity Limit  
FROVATRIPTAN SUCCINATE FROVA TABLET N Quantity Limit  
FROVATRIPTAN SUCCINATE FROVATRIPTAN SUCCINATE TABLET N Quantity Limit  
RIZATRIPTAN BENZOATE MAXALT MLT TAB RAPDIS N Quantity Limit  
RIZATRIPTAN BENZOATE RIZATRIPTAN 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 ZOMIG ZMT TAB RAPDIS N Quantity Limit  
ZOLMITRIPTAN ZOLMITRIPTAN ODT TAB RAPDIS N Quantity Limit  
ZOLMITRIPTAN ZOMIG TABLET N Quantity Limit  
ZOLMITRIPTAN ZOLMITRIPTAN TABLET N Quantity Limit  
ELETRIPTAN HBR RELPAX TABLET Quantity Limit