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Antimigraine Drugs

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Antimigraine Drugs

Drugs

Quantity Limits

Amerge (Naratriptan HCL) 1mg and 2.5mg Tablets 

 9 Tablets per 5 Days in 30 day period

Axert (Almotriptan Malate) Tablets 

 6.25mg - 12 Tablets per 6 Days in 30 day period                 12.5mg - 12 Tablets per 6 Days in 30 day period

Cafergot (Ergotamine Tartrate - Caffeine) 2mg - 100mg Suppositories 

 25 Suppositories per 30 Days

Cafergot (Ergotamine Tartrate - Caffeine) 1mg - 100mg Tablets  

 50 Tablets per 30 Days

Frova (Frovatriptan Succinate) 2.5mg Tablets 

 9 Tablets per 3 Days in 30 day period

Imitrex (Sumatriptan Succinate) 25mg, 50mg and 100mg Tablets 

 18 Tablets per 9 Days in 30 day period

Imitrex (Sumatriptan Succinate) 4mg/0.5ml and 6mg/0.5ml Kits 

 4 Kits per 2 Days in 30 day period

Imitrex (Sumatriptan Succinate) 4mg/0.5ml and 6mg/0.5ml Vials 

 4 Vials per 30 Days

Imitrex (Sumatriptan) 5mg and 20mg Nasal Spray 

 12 Nasal Units per 12 Days in 30 day period

Maxalt (Rizatriptan Benzoate) 5mg and 10mg Tablets 

 12 Tablets per 4 Days in 30 day period

Maxalt MLT (Rizatriptan Benzoate) 5mg and 10mg Rapdis Tablets 

 12 Tablets per 4 Days in 30 day period

Migranal (Dihydroergotamine Mesylate) 1ml Ampules and 1 ml Vials for Nasal Spray

 8 Ampules or 8 vials per 8 Days in 30 day period

Relpax (Eletriptan Hydrobromide) 20mg and 40mg Tablets               

 12 Tablets per 6 Days in 30 day period                       

Treximet (Sumatriptan Succinate - Naproxen Sodium) 85mg - 500mg Tablets 

 9 Tablets per 30 Days

Zomig (Zolmitriptan) 5mg Nasal Spray

  6 Nasal Units per 3 Days in 30 day period

Zomig (Zolmitriptan) Tablets 

 2.5mg - 12 Tablets per 6 Days in 30 day period                   5mg - 6 Tablets per 3 Days in 30 day period

Zomig ZMT (Zolmitriptan) Rapdis Tablets

 2.5mg - 12 Rapdis Tablets per 6 Days in 30 day period       5mg - 6 Rapdis Tablets per 3 Days in 30 day period
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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