What Can You Do When Your Insurance Limits Your Migraine Prescriptions?
Last updated: February 2023
If you use prescription medications to treat your migraine attacks, you may have had the experience of bringing a prescription to the pharmacy only to be told your insurance plan will not cover it the way the doctor has written it. Some insurance companies will only cover a small portion of the doses requested by your doctor. If your doctor has authorized you to have a certain number of doses, why does this happen, and what can you do about it?
Why do insurance companies have prescription limits?
Insurance companies are usually in the business of making money. Even those that aren't for-profit businesses still try to control their spending. If they were to cover every single prescription medication as written by a doctor there is really no limit to the amount of money each patient could conceivably cost the insurance company. Furthermore, some medications are much more expensive than others. Triptans (such as Imitrex, Relpax, and Maxalt) certainly fall into one of the pricier categories. Even though most of us would agree doctors and patients aren't likely to abuse prescription insurance coverage, insurance companies try to prevent out-of-control spending by imposing coverage limits. As a way to establish what they consider a reasonable limit, insurance companies usually cover the dose an average patient needs for a month's time. This number can seem rather arbitrary, unfortunately. Some patients will only need one or two doses a month, while others will need as many as three doses a week.
Can pharmacies split medication packages?
If you're lucky your insurance company will cover a full pack of whatever kind of triptan you use (such as a six-pack box of Zomig nasal spray) under their regular coverage limits. If you're not so lucky, the company may only give you a portion of that amount. Some pharmacies will not do this. Even though this kind of policy can be frustrating, I understand where the pharmacies are coming from. If most insurance companies will cover an entire pack for their patients, what are pharmacies supposed to do with two or three leftover doses? It will probably take some calling around to find a pharmacy willing to do this for you. I have had good luck with the Walgreens Pharmacy in my neighborhood being willing to split packages for me. This is usually decided on a store-by-store basis, so asking to speak with the pharmacy manager might help you convince a store to help you out. If you don't ask, you'll never know. Pointing out politely that you're a regular customer might be helpful, too.
What is prior authorization?
Of course, you don't have to accept the insurance company's first "no" as the final answer, and you really shouldn't. You can ask your doctor for what is known as prior authorization. A prior authorization is a request made by your doctor to the insurance company stating it is a medical necessity for you to have something other than what the insurance company says they will pay for. Doctors and pharmacies are very familiar with this process. If they don't offer to do this for you just ask what you need to do to get the process started.
If a prior authorization is approved it should be good for a full year, meaning the prescription should be filled as requested by your doctor every month until a year has passed. At that time, your doctor will have to submit another prior authorization request.
What happens when you need a refill?
Sometimes I have trouble getting a refill to go through on a prescription even after we've received the prior authorization approval. If I tell the pharmacy staff that we got the prior authorization on X date they are usually able to get the prescription to go through my insurance plan without needing to contact the insurance company or holding up my prescription. I don't know how they do it, but they have all kinds of ways of making things work, given their vast experience dealing with insurance companies. Pharmacy employees are one of your best allies when you're dealing with insurance company limits.
How else can doctors help?
If the limits imposed by your insurance company don't meet your needs, ask your doctors about getting samples. Doctors' offices are usually overflowing with prescription samples. Primary care physician offices sometimes don't have very many triptans on hand, but often neurologists have the pot of gold at the end of the rainbow and are more than happy to help their patients out.
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