Migraine Agents Quantity Limit Program Summary

Transcription

1 Migraine Agents Quantity Limit Program Summary Program applies to GenRx Open, GenRx Closed, Health Insurance Marketplace, FlexRx Open, FlexRx Closed and Medicaid. For the GenRx Closed Formulary, nonpreferred agents will require a formulary exception request and if approved, the quantity limit will also apply. GenRx and FlexRx standard quantity limit program. FDA APPROVED INDICATIONS AND DOSAGE 1-13,16 Acute treatment, Acute treatment, Acute treatment, migraine attacks migraine cluster headache Drug with/without headaches episodes aura (adults) (adolescents a ) (adults) Amerge (naratriptan) 1, 2.5 tablets Axert (almotriptan) 6.25, 12.5 tablets Frova (frovatriptan) 2.5 tablet Imitrex, Sumatriptan 25, 50, 100 tablets Imitrex (sumatriptan) nasal spray 5, or 20 /spray Imitrex, Alsuma, Sumavel, Sumatriptan (sumatriptan) injectable 4 or 6 subcutaneous Maxalt, Maxalt MLT (rizatriptan) 5 or 10 Dosage and Administration Schedule b Initial dose: 1 or 2.5 dose: 4 hours Max dose/24 hours: 5 Initial dose: 6.25 or 12.5 Max dose/24 hours: 25 Initial dose: 2.5 Max dose/24 hours: 7.5 Initial dose: 25 to 100 Max dose/24 hours: 200 Initial dose: 5 or 10 (1-2 sprays) or 20 (1 spray) Max dose/24 hours: 40 Initial dose: 4 or 6 SC dose: 1 hour Max dose/24 hours: 12 Initial dose: 5 or 10 MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 1 of 12

2 Drug Acute treatment, migraine attacks with/without aura (adults) Acute treatment, migraine headaches (adolescents a ) Acute treatment, cluster headache episodes (adults) Dosage and Administration Schedule b tablets Max dose/24 hours: 30 Relpax Initial dose: 20 or (eletriptan) 40 20, 40 tablets Max dose/24 hours: 80 Treximet (sumatriptan/ naproxen sodium 85/500 tablet Zecuity (sumatriptan) 6.5 /4 hours iontophoretic transdermal system Zomig, Zomig ZMT (zolmitriptan) 2.5 or 5 tablets Zomig (zolmitriptan nasal spray) 2.5 /spray 5/spray a - (12-17 years of age [whose attacks usually last 4 hours]) b - Min=minimum; Max=maximum Initial dose: One 85/500 tablet Max Dose/24 hours: Two 85/500 tablets Initial dose: 1 transdermal system applied to skin of upper arm or thigh : 2 hours Max dose/24 hours: 2 transdermal systems Initial dose: 2.5 or 5 Max dose/24 hours: 10 Initial dose: 2.5 ; Maximum single dose: 5 Max dose/24 hours: 10 Drug Cafergot, Migergot (ergotamine tartrate/ caffeine) rectal suppositories Cafergot (ergotamine tartrate/ caffeine tablets D.H.E. 45 (dihydroergotamine mesylate) 1 /ml injection FDA-Approved Indication To abort or prevent vascular headache, e.g., migraine, migraine variants or so-called histaminic cephalgia. To abort or prevent vascular headache, e.g., migraine, migraine variants or so-called histaminic cephalgia. The acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache Dosage and Administration Schedule b Initial dose: 1 suppository at the start of an attack dose: 1 hour Max dose/attack: 2 suppositories Max dose/week: 5 suppositories Initial dose: 2 tablets at the start of attack dose: ½ hour 1 additional tablet every ½ hour, if needed for full relief Max dose/attack: 6 tablets Max dose/week: 10 tablets Initial dose: 1 ml at the start of an attack dose: 1 hour Max dose/24 hours: 3 ml IM/SQ or 2 ml IV Max dose/week: 6 ml MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 2 of 12

3 FDA-Approved Drug Indication episodes. The acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes. a - (12-17 years of age [whose attacks usually last 4 hours]) b - Min=minimum; Max=maximum Ergomar (ergotamine mesylate) 2 sublingual tablets Dosage and Administration Schedule b Initial dose: 2 (1 tablet) at the start of an attack dose: ½ hour Max dose/24 hours: 3 tablets Max dose/week: 5 tablets Drug Migranal (dihydroergotamine mesylate) Nasal spray 1 ml ampule (4 / ml) 0.5 per spray [Stadol NS] (butorphanol tartrate) 10 /ml nasal spray FDA-Approved Indication The acute treatment of migraine attacks with or without aura. The management of pain when the use of an opioid analgesic is appropriate. a - (12-17 years of age [whose attacks usually last 4 hours]) b - Min=minimum; Max=maximum Dosage and Administration Schedule b Initial dose: 1 spray in each nostril. dose: 15 minutes Migranal should be administered in each nostril, for a total dosage of four sprays (2.0 ). Studies have shown no additional benefit from acute doses greater than 2.0 for a single migraine administration. The safety of doses greater than 3.0 in a 24-hour period and 4.0 in a 7-day period has not been established. 1 (one spray in one nostril). dose: minutes May be repeated in 3-4 hours as required after the second dose of the sequence. All products in the above chart are indicated for the acute treatment of migraine attacks with or without aura in adults. 1-13,16 Use only after a clear diagnosis of migraine has been established These products are not intended for the prophylactic therapy of migraine attacks, or for management of hemiplegic or basilar migraine. 1-13,21 Safety and efficacy of most triptan products have not been established for cluster headache. 1-13,16 Only sumatriptan injection formulations have the additional FDA approved indication for cluster headaches. 4 While the incidence is rare, the triptans have been associated with angina, myocardial infarction (MI), cardiac arrhythmias, hypertension, or stroke, particularly when they were used in patients with vascular risk factors. 1-13,16 Triptans should be used with extreme caution in these patients or those with a suspected history of coronary artery disease. Triptans should not be used in patients with uncontrolled hypertension, ischemic heart disease, peripheral vascular disease, or cerebrovascular disease. Triptans should not be used within 24 hours of treatment with another 5-HT1 agonist, or an ergotamine-containing or ergot-type medication like dihydroergotamine or methysergide. 1-13,16 CLINICAL RATIONALE Migraine Headaches Medical Letter Treatment Guidelines (2013) suggest a triptan is the drug of choice for treatment of moderate-to-severe migraine. Use of a triptan early in an attack when pain is still mild to moderate in intensity can improve outcomes. Patients who do not respond to one triptan may respond to another. 22 The injectable and possibly the nasal-spray formulations may be useful for patients with nausea and/or vomiting, and they have a more rapid onset of action than the MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 3 of 12

4 oral tablets. Subcutaneous (SC) sumatriptan is the fastest-acting and most effective triptan formulation. SC sumatriptan produces relief within 2 hours in about 80% of patients with moderate/severe migraine. Sumatriptan nasal spray has produced relief in about 60% of patients after 2 hours, about the same as oral sumatriptan, which has been effective in about 50% to 60% of patients with acute migraine after 2 hours and in about 70% after 4 hours. The oral short-acting triptans almotriptan, eletriptan, rizatriptan and zolmitriptan are similar in efficacy and speed of onset to sumatriptan. Zolmitriptan, like sumatriptan, is also available as a nasal spray; compared to sumatriptan, fewer patients complain about its taste. Naratriptan and frovatriptan have longer half-lives and have a slower onset of action and lower initial response rate than other triptans. In patients with moderate-to-severe migraine, the rate of recurrence within 24 hours after treatment with a triptan is generally 20% to 40%; it may be slightly lower with naratriptan and frovatriptan. Recurrences usually respond to a second dose of triptan. The American Academy of Neurology and the American Headache Society guidelines (2012) on pharmacologic treatment for episodic migraine prevention in adults state that frovatriptan is established as effective and should be offered for short-term menstrually associated migraine (MAMs) prevention (Strong Evidence). Naratriptan and zolmitriptan are probably effective and should be considered for short-term MAMs prevention (Moderate Evidence). 18 The Institute for Clinical Systems Improvement (ICSI, 2012) Guideline Diagnosis and Treatment of Migraine Headache states that triptans are considered to have equal efficacy and are more effective at halting migraine pain at mild levels than if the headache is more severe. 19 National Institute for Health and Clinical Excellence (NICE) Clinical Guidance: Diagnosis and management of headaches in young people and adults 2012 state that for migraine headache with or without aura (acute treatment), an oral triptan or an oral triptan with an NSAID is recommended taking into account the person s preference, comorbidities, and risk of adverse events. For people whom oral preparations are ineffective or not tolerated, a nasal triptan is recommended. Cluster headache-acute treatment-use of 100% oxygen and/or subcutaneous or nasal triptan are recommended. 20 The American Academy of Neurology 2010 Guideline: Acute and preventive pharmacologic treatment of cluster headache state that sumatriptan subcutaneous injection and zolmitriptan nasal spray are recommended for acute treatment of cluster headaches. 17 Triptan Formulations Reviews evaluating sumatriptan oral tablet, nasal spray, and subcutaneous injection vs. placebo or other treatments found the NNT for a pain-free response at two hours was 6.1 for the 50 tablet, 4.7 for the 100 tablet, 2.3 for the 6 SC injection, and 4.7 for the nasal spray. 23 A systematic review and meta-analysis of 74 RCTs of oral triptans vs placebo or other triptans for acute treatment of migraine has shown that all seven triptans are superior to placebo, with a significantly greater odds of being pain free at two hours compared with placebo. Though this meta-analysis found differences in efficacy between the various tablet formulations of triptans, in clinical practice differences between patients seem more important than the differences between drugs. The response of individuals with migraine to a specific acute drug is unpredictable. If a patient does not respond well to one triptan, other triptans should be tried in subsequent attacks. 23 Oral formulations are appropriate when nausea is mild to moderate and vomiting is absent at the time of treatment. Because comparative studies do not clearly establish superiority of one oral triptan over another, a specific agent may be chosen on the basis of formulary availability and previous therapeutic trials. Subcutaneous sumatriptan is the fastest and most efficacious. It is indicated for migraine accompanied by severe nausea or vomiting, for migraines already established by the time of awakening, or in patients who do not respond consistently to oral or nasal preparations. 24 MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 4 of 12

5 Ergotamines Cafergot, Migergot suppositories 36,37 The usual recommended dose for initial rectal administration is 1 suppository at the start of an attack. Early administration at the first sign of an attack gives maximum effectiveness. If adequate pain relief is not achieved after 1 hour, a second suppository may be administered rectally. Two suppositories is the maximum dose for an individual attack. Total weekly dosage should not exceed 5 suppositories. Cafergot and Migergot suppositories should not be used for chronic daily administration. 36,37 Cafergot, ergotamine tartrate/caffeine tablets 38 For the best results, dosage should start at the first sign of an attack. Take 2 tablets at the start of attack; 1 additional tablet every ½ hour, if needed for full relief. The maximum adult dosage of Cafergot and ergotamine tartrate/caffeine tablets should not exceed six tablets for any one attack. Total weekly dosage should not exceed ten tablets. Ergotamine tartrate/caffeine tablets should not be used for chronic daily administration. In carefully selected patients, with due consideration of maximum dosage recommendations, administration of the drug at bedtime may be an appropriate short-term preventive measure. 38 Ergomar 39 The usual recommended dose for initial sublingual administration is one 2 tablet placed under the tongue at the first sign of an attack. For best results, dosage should start at the first sign of an attack. Early administration at the first sign of an attack gives maximum effectiveness. If necessary, one tablet should be taken at half-hour intervals thereafter but dosage must not exceed three tablets in 24 hours. Total weekly dosage should not exceed 5 tablets (10 ) in any one week. Ergomar sublingual tablets should not be used for chronic daily administration. 39 D.H.E. 45, dihydroergotamine mesylate injection USP 40,41 The usual recommended dose for initial intravenous, intramuscular, or subcutaneous injection is 1 ml administered at the start of an attack. The dose can be repeated, as needed, at 1-hour intervals to a total dose of 3 ml for intramuscular or subcutaneous delivery or 2 ml for intravenous delivery in a 24-hour period. The total weekly dosage should not exceed 6 ml. D.H.E. 45 and dihydroergotamine mesylate injection should not be used for chronic daily administration. 40,41 Migranal 42 Prior to administration of Migranal the sprayer must be primed (pumped 4 times in the air). Each spray delivers 0.5 of Migranal. Once the sprayer has been prepared, it must be discarded with any remaining drug after 8 hours. 42 One spray (0.5 ) of Migranal should be administered in each nostril. Fifteen minutes later, an additional one spray of Migranal should be administered in each nostril, for a total dosage of four sprays (2.0 ). Studies have shown no additional benefit from acute doses greater than 2.0 for a single migraine administration. The safety of doses greater than 3.0 in a 24-hour period and 4.0 in a 7-day period has not been established. Migranal should not be used for chronic daily administration. 42 Butorphanol tartrate nasal spray 43 For butorphanol tartrate nasal spray, proper patient selection, dose and prescribing limitations, appropriate directions for use, and frequent monitoring are important to minimize the risk of abuse and physical dependence. 43 Factors to be considered in determining the dose are age, body weight, physical status, underlying pathological conditions, use of other drugs, type of anesthesia to be used, and surgical procedure involved. Use in the elderly, in patients with hepatic or renal disease, or in labor requires extra caution. The following doses are for patients who do not have impaired hepatic or renal function and who are not on CNS active drugs. MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 5 of 12

6 Special care should be exercised in administering butorphanol to patients with a history of drug abuse or to patients receiving the drug on a continuous basis for an extended period. 43 The usual recommended dose for initial nasal administration is 1 (one spray in one nostril). Adherence to this dose reduces the incidence of drowsiness and dizziness. If adequate pain relief is not achieved within minutes, an additional 1 dose may be given. The initial dose sequence outlined above may be repeated in 3-4 hours as required after the second dose of the sequence. 18 Depending on the severity of the pain, an initial dose of 2 (one spray in each nostril) may be used in patients who will be able to remain recumbent in the event drowsiness or dizziness occurs. In such patients single additional 2 doses should not be given for 3-4 hours. 43 ADDITIONAL INFORMATION - Migraine Frequency and Prophylactic Therapy Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered. 1 Guidelines state that first-line therapies for migraine prophylaxis in adults were propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate. Agents that could be used as second-line therapy for migraine prophylaxis in adults (listed by evidence of effectiveness) included gabapentin, naproxen, timed-release dihydroergotamine mesylate, candesartan, lisinopril, atenolol, metoprolol, nadolol, fluoxetine, or verapamil. 1,2 The European Federation of Neurological Societies (EFNS) guidelines from support the use of β-blockers (propranolol and metoprolol), calcium channel blockers, and valproate as first-line prophylactic agents, as well as topiramate. Amitriptyline, naproxen, and bisoprolol are listed as second choices. 3 Silverstein s review (2009) 4 lists the following as having high efficacy: propranolol, timolol, amitriptyline, valproate, topiramate, flunarizine [not available in the U.S.]. This review considers the following to have some efficacy: NSAIDs, atenolol, metoprolol, nadolol, verapamil, and gabapentin. 4 Medical Letter treatment guidelines (2013) 5 suggest menstrual or other predictable migraine attacks may be prevented by a brief course of NSAID, ergot alkaloid or triptan. For continuous prophylaxis, beta-blockers are commonly used; propranolol and timolol are FDA approved, but metoprolol, nadolol, and atenolol also have been effective. Antiepileptic drugs such as valproate and topiramate have been effective in decreasing migraine frequency in 50% of patients; gabapentin has been used with varying degrees of success. Calcium channel blockers are also used but the evidence for their effectiveness is weak. Tricyclic antidepressants can prevent migraine in some patients but often cause sedation, dry mouth and weight gain. In small double-blind studies, lisinopril and candesartan have reduced migraine frequency. 5 A Cochrane review (2004) 6 of anticonvulsants for migraine prophylaxis states that valproic acid/sodium valproate has proven efficacy for this use. This review suggested that gabapentin needed further evaluation and that topiramate had reasonable evidence to support its use. 6 In 2012, the American Academy of Neurology (AAN) updated its guidelines for migraine prevention. 16,17 Strongly recommended agents include divalproex sodium/sodium valproate, topiramate, metoprolol, propranolol, and timolol; medications listed as probably effective include amitriptyline, venlafaxine, atenolol, and nadolol; and those possibly effective are lisinopril, candesartan, clonidine, guanfacine, carbamazepine, nebivolol and pindolol. 16,17 Based on published data from a 1989 survey 7 the median frequency of migraine attacks is 1.5 per month, and the median duration of an attack is 24 hours; at least 10% of patients have weekly attacks, and 20% have attacks lasting two to three days. 7 Additional surveys from the mid to late 1990 s have confirmed these data Survey results continue to report a median MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 6 of 12

7 attack duration of 24 hours; 54% to 63% of patients report monthly attacks and 13% to 25% report weekly attacks Evidence-based guidelines and published practice parameters from the American Academy of Neurology (AAN) for the pharmacologic management of migraine headaches suggest that acute therapy should be limited to no more than two headache days per week to guard against medication-overuse headache. 12 AAN guidelines recommend preventive treatment where the frequency of attacks has increased the use of acute medications to a level that would increase the potential for medication overuse headaches. 12,13 Medication overuse headache is now included in the International Classification of Headache Disorders. 14,15 According to this classification, medication overuse headache can be diagnosed when headaches occur on 15 or more days per month, the pain is characterized as bilateral, dull, and of light to moderate intensity, drug intake includes ergots, triptans and opioids for ten or more days per month or analgesics are used for 15 or more days per month for at least three months, and the headache disappears after withdrawal For additional clinical information see Prime Therapeutics Formulary Chapter 10.4A: Migraine Products - Triptans and 10.4B - Migraine: Others. REFERENCES 1. Axert Prescribing Information. Ortho-McNeil Neurologics, Titusville NJ. August Relpax Prescribing Information. Pfizer Pharmaceuticals, NY, NY. May Frova Prescribing Information. Endo Pharmaceuticals, Inc., Chadds Ford PA. October Amerge Prescribing Information. GSK, Triangle Park, NC. October Maxalt Prescribing Information. Merck& Co, Inc, Whitehouse Station, NJ. November Imitrex Injection Prescribing Information. GSK, Research Triangle Park, NC. September Imitrex Nasal Spray Prescribing Information. GSK, Research Triangle Park, NC. November Imitrex Tablet Prescribing Information. GSK, Research Triangle Park, NC. November Zomig, ZMT Prescribing Information. AstraZeneca Pharmaceuticals, Wilmington Delaware. September Zomig Nasal Spray Prescribing Information. AstraZeneca Pharmaceuticals, Wilmington Delaware. September Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalagia. 1998; 8(Suppl 7): Silberstein SD for the US Headache Consortium. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55: Snow V, Weiss K, Wall EM, et al. Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headache. Ann Intern Med. 2002; 137: Farkkila M, Olesen J, Dahlof C, et al. Eletriptan for the treatment of migraine in patients with previous poor response or tolerance to oral sumatriptan. Cephalalgia. 2003; 23(6): Diener HC, Gendolla A, Gebert I, et al. Almotriptan in migraine patients who respond poorly to oral sumatriptan: a double-blind, randomized trial. Headache. 2005; 45(7): Stark S, Spierings EL, McNeal S, et al. Naratriptan efficacy in migraineurs who respond poorly to oral sumatriptan. Headache.2000; 40(7): MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 7 of 12

8 17. FDA. Public Health Advisory (triptans, SSRIs, or SNRIs). Available at: Accessed February Silberstein SD, Freitag FG. Preventive treatment of migraine. Neurology. 2003;60:S38 S Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS. EFNS guideline on the drug treatment of migraine revised report of an EFNS task force. European Journal of Neurology. 2009;16(9): Silverstein SD. Preventive migraine treatment. Neurol Clin. 2009;27: Medical Letter: Treatment Guidelines. Drugs for migraine. 2008;6(67): Chronicle E, Mulleners W. Anticonvulsant drugs for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2004, Issue 3. Art. No.: CD DOI: / CD pub Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States: relation to age, income, race and other sociodemographic factors. JAMA 1992;267: Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41: Lipton RB, Scher AI, Kolodner K, et al. Migraine in the United States: epidemiology and patterns of health care use. Neurology. 2002;58: Steiner TJ, Scher AI, Stewart WF, et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia. 2003;23: Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States; disability and economic costs. Arch Intern Med. 1999;159: Matchar DB, Young WB, Rosenberg JH, Pietrzak MP, Silbertein SD,Lipton RB, Ramadan NM. Evidence-based guidelines for migraine headache in the primary care setting: Pharmacological management of acute attacks. American Academy of Neurology Available at: Accessed July 31, Ramadan NM, Silberstein SD, Freitag FG, Gilbert TT, Frishberg BM. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Prevention of Migraine. American Academy of Neurology Available at: Accessed May 22, Olesen J, Lipton RB. Headache classification update Current Opinion in Neurology 2004;17(3): Limmroth V, Katsarava Z. Medication overuse headache. Current Opinion in Neurology. 2004;17(3): Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for the treatment of cluster headache. JAMA 2009;302(22): American Headache Society. Treatment of cluster headaches Available at: Accessed February Alsuma prescribing information. King Pharmaceuticals. June Treximet Tablets prescribing information. GlaxoKlineSmith. April Cafergot Suppositories prescribing information. Novartis Pharmaceuticals. July Migergot Suppositories (Ergotamine Tartrate and Caffeine Suppositories USP) prescribing information. G&W Laboratories Inc. April Cafergot Tablets prescribing information. Novartis Pharmaceuticals Corporation. March Ergomar Sublingual Tablets prescribing information. Harvest Pharmaceuticals, Inc. August D.H.E.45 Injection prescribing information. Novartis Pharmaceuticals. September Dihydroergotamine Mesylate Injection USP prescribing information. Bedford Laboratories. January MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 8 of 12

9 42. Migranal prescribing information. Valeant Pharmaceuticals International. March Butorphanol Tartrate Nasal Spray prescribing information. Roxane Laboratories, April 2003; Apotex Inc., May Sumavel DosePro prescribing information. Zogenix Inc. November Zecuity prescribing information. NuPathe Inc. March Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: American Academy of Neurology/American Headache Society. Neurology 2012;78: National Institute for Health and Clinical Excellence (NICE). Headaches: diagnosis and management of headaches in young people and adults. Guideline # Accessed November MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 9 of 12

10 Triptans Quantity Limit OBJECTIVE The intent of the Triptans Quantity Limit (QL) program is to provide automatic approval for patients with three or fewer migraine or cluster headaches per month (two headache days per episode) and to require individual evaluation through the prior authorization process for patients who have more headaches per month and exceed the limit. Additionally, the intent of the quantity limit criteria together is to ensure that patients and prescribers address the current guidelines for the prevention and treatment of migraine and/or cluster headache. Requests for larger quantities will be evaluated through the Clinical Review process when the prescriber provides evidence that dosing with higher quantities is appropriate for the patient. The quantity limit edit applies to both generic and brand triptan products. QUANTITY LIMIT TARGET DRUGS - RECOMMENDED LIMITS Brand (generic) GPI Quantity Limit per Month Alsuma (sumatriptan) Injection 6 /0.5 ml single dose injection device D doses (6 packages of 2) Amerge (naratriptan) Tablets 1 a tablets (2 packages of 9) 2.5 a tablets (2 packages of 9) Axert (almotriptan) Tablets 6.25 a tablets (2 packages of 6) 12.5 a tablets (1 package of 12) Frova (frovatriptan) Tablets tablets (2 packages of 9) Imitrex (sumatriptan) Injection 4 STATdose system a D doses (6 packages) 4 STATdose refill a E doses (6 packages) 6 STATdose system a D doses (6 packages) 6 STATdose refill a E doses (6 packages) 6/0.5mL single dose vial ml (2 packages) (5 x 0.5 ml/package) a Sumatriptan Injection 4 /0.5 ml vial a doses (12 vials) 6 /0.5 ml syringe b E doses (12 vials) Imitrex, Sumatriptan (sumatriptan) Nasal Spray units (2 packages of 6) units (2 packages of 6) Imitrex (sumatriptan) Tablets 25 a tablets (2 packages of 9) 50 a tablets (2 packages of 9) 100 a tablets (2 packages of 9) Maxalt (rizatriptan) MLT Tablets 5 a tablets (1 package of 18) 10 a tablets (1 package of 18) Maxalt (rizatriptan) Tablets 5 a tablets (1 package of 18) 10 a tablets (1 package of 18) Relpax (eletriptan) Tablets tablets (2 packages of 6) tablets (2 packages of 6) a - available as a generic, included in quantity limit program b available as generic only, included in quantity limit program MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 10 of 12 Copyright Prime Therapeutics LLC. 07/2015 All Rights Reserved

11 c available as brand only Brand (generic) GPI Quantity Limit per Month Sumavel DosePro (sumatriptan) Injection 4 /0.5 ml single dose injection device D doses (2 packages of 6) 6 /0.5 ml single dose injection device D doses (2 packages of 6) Treximet (sumatriptan/naproxen) Tablets 85/ tablets (2 packages of 9) Zecuity (sumatriptan) Iontophoretic Transdermal System 6.5 /4 hours transdermal systems Zomig (zolmitriptan) Nasal Spray 2.5 /100 microliters units (2 packages of 6) 5 /100 microliters units (2 packages of 6) Zomig (zolmitriptan) Tablets 2.5 a tablets (2 packages of 6) 5 a tablets (4 packages of 3) Zomig (zolmitriptan) ZMT Tablets 2.5 a tablets (2 packages of 6) 5 a tablets (4 packages of 3) Cafergot, Migergot (ergotamine tartrate/ caffeine) Rectal suppositories 2/100 suppositories suppositories Cafergot a (ergotamine tartrate/ caffeine) Tablets 1/100 tablets tablets D.H.E. 45 a (dihydroergotamine mesylate) Injection 1 /ml injection ampules Ergomar (ergotamine mesylate) Tablets 2 sublingual tablets tablets Migranal (dihydroergotamine mesylate) Nasal Spray Nasal spray 1 ml ampule (4 / ml) 0.5 per spray ml (2 packages of 8-1 ml ampules) [Stadol NS ] b (butorphanol tartrate) Nasal Spray 10 /ml nasal spray canisters a - available as a generic, included in quantity limit program b - available only as a generic, included in quantity limit program PRIOR AUTHORIZATION CRITERIA FOR APPROVAL For Triptans, Treximet, butorphanol tartrate nasal spray, AND Migranal Quantities above the program set limit will be approved when ONE of the following is met: 1. ALL of the following: a. The patient has a diagnosis of migraine headache AND b. ONE of the following: i. The patient is currently using migraine prophylactic medication OR ii. The patient has a documented intolerance, FDA labeled contraindication, hypersensitivity to or refusal to use prophylactic migraine medication AND c. The patient has been evaluated for and does not have medication overuse headache AND d. Any current use of another triptan or an ergotamine product will be discontinued OR MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 11 of 12 Copyright Prime Therapeutics LLC. 07/2015 All Rights Reserved

12 2. BOTH of the following: a. The patient has a diagnosis of cluster headache AND b. The requested product is an injection or nasal spray Length of Approval: 12 months [For a diagnosis of migraine, the quantity requested up to the FDA labeled maximum dose allowed per 24 hours will be approved.] For Ergotamine, Ergot Combinations, and dihydroergotamine (Cafergot, Migergot, ergotamine tartrate/ caffeine, Ergomar, D.H.E 45 injection, dihydroergotamine mesylate injection USP) [EXCEPT Migranal, which is included above] 1. The patient needs more medication than the limit in the Recommended Quantity Limits table AND 2. The prescriber has submitted documentation in support of therapy with a higher dose for the intended diagnosis. Length of Approval: 12 months [For a diagnosis of migraine, the quantity requested up to the FDA-labeled maximum dose allowed per 24 hours will be approved.] MN_CS_Migraine_Agents_QL_ProgSum_AR0615_r0915 Page 12 of 12 Copyright Prime Therapeutics LLC. 07/2015 All Rights Reserved