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Includes patient and prescriber identity details, drug selection fields, dosing and therapy parameters, and required clinical documentation. Covers eligibility criteria across all requests plus migraine-specific criteria, such as prophylactic medication use, prior treatment history, medication overuse headache rule-out, and combination therapy plans. 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For faster coverage determinations, [go to](go to www.CoverMyMeds.com)[ ](go to www.CoverMyMeds.com)[www.CoverMyMeds.com](go to www.CoverMyMeds.com).  \nOnly the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. Incomplete forms will be returned for additional information. The following documentation is required for preauthorization consideration. For formulary information visit [primetherapeutics.com/commercial-formularies](primetherapeutics.com/commercial-formularies).  \nWhat is the priority level of this request?  Standard  \n Date of service (if applicable) :    \n Urgent ( Note: Urgent is defined as when the prescriber believes that waiting for a standard review could seriously harm the patient’s life, health, or ability to regain maximum function.)  \nToday’s Date:    \nPATIENT INFORMATION  \nPatient Last Name:   Patient First Name:   Patient ID:   Date of Birth:   Patient Phone:   Patient Street Address:   City:   State:   Zip:    \nSex:  Male  Female Height:    in.  cm Weight:    lbs.  kg  \nAllergies:    \nPRESCRIBER INFORMATION  \nPrescriber Last Name:   Prescriber First Name:   Specialty:   Email:   Prescriber NPI:   DEA:   Prescriber Phone:   Prescriber Fax:   Prescriber Street Address:   City:   State:   Zip:    \nDRUG INFORMATION  \nDrug Name:   Drug Form:   Drug Strength:   Dosing Frequency:   Length of Therapy:   Quantity:    \nNumber of Refills:   Day Supply:    New Therapy  Renewal If renewal, date therapy initiated:   If renewal, duration of therapy (specific dates):   to    \nCRITERIA FOR ALL REQUESTS  \nNote: Please attach any additional information that should be considered with this request.  \nPatient’s Diagnosis:  \n Migraine headache  \n Cluster headache  \n Other (ICD code plus description):  \nICD Code:   ICD Description:    \n1. Is the patient currently treated with the requested medication?  \n Yes  No  \n2. Has the patient been treated with the requested agent within the past 90 days?  \n Yes  No  \nIf Yes, is the patient at risk if therapy is changed?  \n Yes  No  \nIf Yes, explain:  \n3. For brand products, does the patient’s medication history include the use of a generic triptan within the past 90 days?  \n Yes  No  \nIf Yes, please specify the generic triptan agents:  \nIf No, does the patient have an intolerance or hypersensitivity to a generic triptan agent?  Yes  No  \nIf Yes, please explain:  \nIf No, does the patient have an FDA labeled contraindication to all generic triptan agents?  \n Yes  No  \nIf Yes, please explain:  \n4. Please list all reasons for selecting the requested medication, strength, dosing schedule, and quantity over alternatives (e.g. , contraindications, allergies, history of adverse drug reactions to alternatives, lower dose has been tried, information supporting dose over FDA max) .  \n5. Please list all medications that the patient has previously tried and failed for treatment of this diagnosis. (Please specify whether the patient has tried brand-name products, generic products, or over-the-counter products.)  \nMedication:   Type:   Date (from):   Date (to):    \nMedication:   Type:   Date (from):   Date (to):    \nMedication:   Type:   Date (from):   Date (to):    \nCRITERIA FOR MIGRAINE HEADACHES  \n6. Is the patient currently using migraine prophylactic medication ( i.e. , anticonvulsants, beta blockers, antidepressants, candesartan, prophylactic use CGRP, onabotulinum toxin A [Botox])?  Yes  No  \nIf No, does the patient have an intolerance or hypersensitivity to an anticonvulsant, beta blocker, antidepressant, candesartan, prophylactic use CGRP, or onabotulinum toxin A?  Yes  No  \nIf Yes, please explain:  \nIf No, does the patient have an FDA labeled contraindication to all anticonvulsants, beta blockers, antidepressants, candesartan, pro","cbCaieV0268vIfMB","https://ap.wps.com/l/cbCaieV0268vIfMB","pdf",1117760,"English","# Patient Information\n# Prescriber Information\n# Drug Information\n# Criteria for All Requests\n## Additional Reasons and Medication History\n# Criteria for Migraine Headaches\n## Migraine Prophylactic Use and Contraindications\n## Medication Overuse Headache and Combination Therapy\n# Attachments and Attestation","[{\"question\":\"Who is allowed to complete the triptan prior authorization form?\",\"answer\":\"Only the prescriber may complete the form.\"},{\"question\":\"What types of reviews does the form support?\",\"answer\":\"The form is for prospective, concurrent, and retrospective reviews.\"},{\"question\":\"What migraine-specific questions must be addressed in the criteria section?\",\"answer\":\"The form asks whether prophylactic migraine medications are currently used and whether contraindications or hypersensitivity apply, whether medication overuse headache has been ruled out, and whether the requested agent will be combined with another acute migraine therapy.\"}]","Choice Prior Authorization Request Form - Triptan Agents - Fax Submission | PDF"]