Serotonin Agonists, Subcutaneous
PDL Reference Documents
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 |
|---|---|---|---|---|---|---|---|
| 00173073902 | IMITREX | sumatriptan succinate | CARTRIDGE | 4 mg/0.5 mL | Y | Y | Quantity Limit |
| 00173047800 | IMITREX | sumatriptan succinate | CARTRIDGE | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 66993008479 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | CARTRIDGE | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 00245080938 | ZEMBRACE SYMTOUCH | sumatriptan succinate | PEN INJCTR | 3 mg/0.5 mL | N | Y | Quantity Limit |
| 00245080989 | ZEMBRACE SYMTOUCH | sumatriptan succinate | PEN INJCTR | 3 mg/0.5 mL | N | Y | Quantity Limit |
| 00173073900 | IMITREX | sumatriptan succinate | PEN INJCTR | 4 mg/0.5 mL | Y | Y | Quantity Limit |
| 00173047900 | IMITREX | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 43598076811 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 43598076823 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 47335027640 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 47335027641 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 55111069305 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 55111069312 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 66993008498 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 72603014101 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 72603014102 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | PEN INJCTR | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 00143963801 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 00143963805 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 55150017301 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 55150017305 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 63323027301 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 65145011801 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 65145011805 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 70594006801 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |
| 70594006802 | SUMATRIPTAN SUCCINATE | sumatriptan succinate | VIAL | 6 mg/0.5 mL | Y | Y | Quantity Limit |