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Choosing the right prescription drug coverage for your migraine needs

When the time comes to select a health insurance program, you not only want to look at things like whether you’ll be required to get referrals to see specialists and which doctors will be covered by the plan. You also want to look at how prescription drugs are covered under the insurance plan.

There are a few ways that prescription drugs can be limited through insurance plans: Formularies, step therapy, prior authorizations and quantity limits are the big ones.

A formulary is a list of drugs that tells you whether the insurance company will cover any part of the cost of a prescription for that medication and if so, at what cost. Formularies are commonly divided up into tiers. Medications under tier one are covered by the insurance company at a high rate of copayment, making those medications the most affordable for you as the consumer. Medications on the second tier are typically covered, but at a lower copayment than those on tier one. Tier three medications are either not covered at all or at a very low rate of copayment.

I recommend you look up the formulary for a plan you’re considering (either ask someone in human resources at work for a list or go online to the insurance company website to find the list). Make a list of the medications you take, including both those you rely on for prevention or daily use and for treatment of acute migraine attacks. Look up each item on the formulary so you can familiarize yourself with how those medications will be covered. Ideally you’ll be able to find a plan that has good coverage of most, if not all of your medications.

Another way insurance companies limit prescription drug coverage is through something called step therapy. Step therapy is when your insurance company requires you to try a cheaper generic medication for your condition before they will cover the cost of a more expensive medication. If you’ve already tried a bunch of medications you can ask your doctor to write a letter telling the insurance company that you’ve already had a trial on that medication, did not achieve good results with it and need to take the more expensive medication.

Insurance companies often limit the amount of medication they will cover for you within a defined time period. Migraineurs often face this with their triptans (Imitrex, Zomig, Relpax, Frova, etc.) These medications are extremely expensive, so insurance companies limit the amount to protect their bottom line. Ask your doctor to request a prior authorization to try to override the limits. Often you can get the company to give you more if your doctor tells them you really need more.

Unfortunately, sometimes insurance companies flat out refuse to cover the cost of a particular medication. Overall I’ve been happy with the Medicare Part D prescription plan I chose, but for some reason they will only cover the anti-nausea medication Zofran (ondansetron) for pregnant women. They absolutely will not cover any part of the cost for migraineurs despite my doctor seeking a prior authorization for me. I have to pay out of pocket for it, but luckily it’s become rather affordable in the generic form, so it’s not a huge financial burden.

Do you have questions about obstacles in your prescription insurance coverage? Please feel free to share them in the comments.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • Frankfishman
    8 months ago

    I hope you will be okay soon.

  • jns192 moderator
    3 years ago

    Diana,
    Great article!
    Insurance has been one of the biggest burdens with migraine treatment.
    I am lucky that I have found great success in treating an acute attack with Cambia (diclofenac). However, it is not only considered a tier 3 drug, they limit the # I can get per month.
    For the longest time, I was only able to get 4 packets a month (though I was dealing with 10+ migraines a month) and it cost $20 per packet.
    I had tried the generic diclofenac tabs (which are tier 1 with no limit) but they are not really effective for me.
    I even tried crushing them to make it more like the cambia powder but to no avail.

    Last year I was thrilled when I found the Cambia manufacturer’s coupon which cut my cost to $5/packet.

    After several phone calls to the insurance company, pharmacy, neurologist and after several letters from my doctor and I, I finally got prior auth to get 12 packets a month.

    They definitely don’t teach us this stuff in school so articles like this are so important and informative.

    -Jillian (Migraine.com Team)

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