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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Triptans are the medication of choice in the treatment of moderate-to-severe attacks and in those patients who do not respond to or do not tolerate NSAIDs. There are several meta-analyses of placebo-controlled trials and head-to-head trials comparing triptans. Endpoints and results with specific agents may differ, but all conclude that although specific (pharmacokinetic) differences among the triptans exist, all 7 oral agents are efficacious in treating acute migraines and have similar safety profiles. Differences in pharmacokinetics and clinical effects may predispose the selection of one triptan over another. Triptan therapy must be individualized. If initial therapy is unsuccessful, an alternative triptan should be accessible to the patient. Subcutaneous delivery of sumatriptan offers the most rapid pain relief of the triptans beginning in 10-15 minutes.
Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society 2012 states the following:
The Institute for Clinical Systems Improvement (ICSI) Guideline Diagnosis and Treatment of Migraine Headache 2012 states the following:
National Institute for Health and Clinical Excellence (NICE) Clinical Guidance: Diagnosis and management of headaches in young people and adults 2012 states the following:
The American Academy of Neurology 2010 Guideline: Acute and preventive pharmacologic treatment of cluster headache states the following:
Previous use of samples or vouchers/coupons will not be considered for authorization.
Brand Triptan products will be approved when ONE of the following is met:
**If the brand name medication is approved, the Plan will only reimburse the same amount that is reimbursed for generic sumatriptan tablet (9 tablets) prescriptions.
POLICY EXCEPTIONSTriptan generic first program is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
07/08/2015: Code Reference section updated for ICD-10.
10/27/2015: Policy section updated to state: Previous use of samples or vouchers/coupons will not be considered for authorization.
02/02/2016: Approved by Pharmacy & Therapeutics (P&T) Committee. Investigative definition updated in policy guidelines section.
05/26/2016: Policy number added.
SOURCE(S)1. Amerge Tablets prescribing information. GlaxoSmithKline. February 2010.
2. Axert Tablets prescribing information. Ortho-McNeil Pharmaceutical, Inc. April 2009.
3. Frova prescribing information. Endo Pharmaceuticals, Inc. April 2007.
4. Imitrex Injection prescribing information. GlaxoSmithKline. February 2010.
5. Imitrex Nasal Spray prescribing information. GlaxoSmithKline. February 2010.
6. Imitrex Tablets prescribing information. GlaxoSmithKline. February 2010.
7. Maxalt Tablets and Maxalt-MLT Tablets prescribing information. Merck & Co, Inc. August 2011.
8. Relpax Tablets prescribing information. Pfizer, Inc. May 2008.
9. Zomig Tablets, Zomig-ZMT Orally Disintegrating Tablets prescribing information. AstraZeneca Pharmaceuticals LP. October 2008.
10. Zomig Nasal Spray prescribing information. AstraZeneca Pharmaceuticals LP. October 2008.
11. Treximet prescribing information. GlaxoSmithKline. December 2009.
12. Alsuma prescribing information. King Pharmaceuticals. June 2010.
13. Sumavel DosePro Prescribing Information. Zogenix, Inc. November 2009
14. ICSI. Health care guideline: diagnosis and treatment of headache2012 Available @ http://www.icsi.org/search.aspx?searchFor=migraine&x=18&y=9. Accessed November 2012.
15. Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine-revised report of an EFNS task force. Eur J Neurology. 2009;16:968-981.
16. Pascual J, Mateos V, Roig C, et al. Marketed oral triptans in the acute treatment of migraine: a systematic review on efficacy and tolerability. Headache. 2007;47(8):1152-1168.
17. Steiner TJ, Fontebasso M. Headache: Clinical Review. BMJ 2002;325:881-6.
18. Francis GJ, Becker WJ, Prinsheim T. Acute and preventive treatment of cluster headache. Neurology 2010;75:463-473.
19. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for the treatment of cluster headache. JAMA 2009;302(22):2451-2457.
20. American Headache Society. Treatment of cluster headaches. 2009 Available at: http://www.americanheadachesociety.org/assets/GoadsbyCluster.pdf. Accessed February 2010.
21. Zecuity prescribing information. NuPathe Inc. January 2013.
22. 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;78:1337-1345.
23. National Institute for Health and Clinical Excellence (NICE). Headaches: diagnosis and management of headaches in young people and adults. Guideline #150 2012. Accessed November 2012 @ www.nice.org.uk/cg150.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.