Serotonin Agonists, Nasal
PDL Reference Documents
- Headache Treatment and Prevention - Apr 03, 2025
- Serotonin Agonists - Aug 06, 2020
- Migraine Treatment and Prevention - May 23, 2019
- Triptans - Mar 31, 2016
- Triptan Scan Summary - May 29, 2014
- Triptans DERP Scan - May 29, 2014
- Drug Class Review: Triptans - Jul 25, 2013
- Class Scan: Triptans - Mar 29, 2012
Drug Use Review Documents
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.
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00245081261 | TOSYMRA | sumatriptan | SPRAY | 10 mg | N | Y | Quantity Limit |
| 00245081289 | TOSYMRA | sumatriptan | SPRAY | 10 mg | N | Y | Quantity Limit |
| 00527185943 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 45802059800 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 45802059806 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 66993008269 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 69097064448 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 71921017061 | SUMATRIPTAN | sumatriptan | SPRAY | 20 mg | Y | Y | Quantity Limit |
| 00527181843 | SUMATRIPTAN | sumatriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 45802061900 | SUMATRIPTAN | sumatriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 45802061906 | SUMATRIPTAN | sumatriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 66993008169 | SUMATRIPTAN | sumatriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 69238235106 | ZOLMITRIPTAN | zolmitriptan | SPRAY | 2.5 mg | Y | Y | Quantity Limit |
| 64896008312 | ZOMIG | zolmitriptan | SPRAY | 2.5 mg | Y | Y | Quantity Limit |
| 45802071100 | ZOLMITRIPTAN | zolmitriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 45802071191 | ZOLMITRIPTAN | zolmitriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 69238235206 | ZOLMITRIPTAN | zolmitriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |
| 64896008412 | ZOMIG | zolmitriptan | SPRAY | 5 mg | Y | Y | Quantity Limit |