Why do insurance companies limit prescription migraine medications? What can a migraine patient do?

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?

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 ever 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.

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.

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 a 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. 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.

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.

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

View Comments (20)
  • Dana
    12 months ago

    My head hurts too much to read all the comments, but I will come back and read them. My comment is even with a prior auth your insurance only allows you to have 9 migraines every 3 months medication-wise. I’d like to give every head honcho at the insurance companies a “please kill me” migraine and then see if they stand by their rule.

  • drewski
    1 year ago

    I LOOKED IN TO THIS!!!! In plain English, it’s because the insurance companies can get away with it. Insurance companies are a money making corperation and their main goal is profit. So any way they can save some money I’m sure they will as anyone probably would.

  • Emily
    6 years ago

    One bit of information: Target splits packages in my prescriptions for sumatriptan (off-brand Imitrex, I’ve gotten two different manufacturers at various times). I think the packs usually come in 8 or 9, and my doctor gives me a prescription for one more than that.

    I’ve got two different drugs for headaches right now, because I can never get enough sumatriptan, so I basically hoard it for the times I really need it. The other (fioricet?) makes me sleepy and dizzy, but it’s all I can do for most of the times.

  • Christine Hennessy
    7 years ago

    When I think about how little I utilize my medical insurance for anything else other than managing my migraines, it irritates me that they still come back and tell me what kind of medication I should be taking for the migraine pain. Who are they to tell me what to take, just to save them some money? I pay a bi-weekly copay AND I pay a copay for each prescription. They don’t even know my medical history, yet they can tell me what medication to take? What a joke!

  • Gina Marie Johnson
    7 years ago

    Or like Frova that comes 9 pills for $300 without insurance $85 with 🙁

  • Laura Kincaid
    7 years ago

    No. With Relpax, you can’t take more than 80 mg in 24 hours. But that is all I’ve ever been told.

  • Lisa Morgan Stephens
    7 years ago

    Insurance is frustrating when it comes to refills of migraine meds, I had to switch to a generic form of Imitrex since they would not pay for much of the Zomig, which worked better on my headaches – now I have to take double the amount of meds & hope I don’t go over my (9) pill limit each month!

  • Laura Kincaid
    7 years ago

    I feel your pain. My insurance only covers 9 Relpax a month with a $55 copay. My dad (works in Mexico) has a pharmacist in Mexico special order the pills for me. My folks end up paying $12 a pill, but I have to have them.

  • Donna Stephens Smith
    7 years ago

    My doctor explained to me that I can not take more than 3 imetrix each week, due to risk for heart damage. So I split the 9 the insurance co. Allows me to be able to have 12 and keep my heart safe. Anyone else heard of this?

  • Judy Collins
    8 years ago

    Has anyone been sucessful in obtaining disablity for migraines.

  • Penny Atwood Chrisco
    7 years ago

    im getting ready to have a hearing in front of a judge for my disability for migraines and another disease that i have. and it requires and attorney.

  • Bonni Currieri Lamey
    7 years ago

    I had to get an attorney to get disability

  • Judy Collins
    8 years ago

    A 6 pack of meds only lasts for two weeks the way my headaches are running and the physician has instructed use. It is frustrating to have 6 relpax knowing my headaches have been requiring either medication or enduring pain for 16 of the last 18 days.

  • Judy Collins
    8 years ago

    Thanks you

  • Charles Jacobs
    8 years ago

    I hope you feel better soon Judy.

  • Heather Zanitsch
    8 years ago

    Where I live, both my old migraine doc and my GP told me that triptan manufacturers were dropping the number of sample pools distributed to docs…I don’t know if anyone else has encountered this but I thought I might mention it. My GP also said that the makers of Frova shipped it to them instead of a rep bringing it in, so they don’t get very many samples of that at all. While my docs were more than happy to help me if I needed triptans, some months it was very difficult to get ahold of many during my cycle, which is when I needed them the most. I don’t take them anymore due to rebound issues, but even DHE is hard for me to get with as many pharmacies there are in my area. The one pharmacy I do go to that can get it has to continually reorder it for me – this past week the pharmacist asked me if I expected to need it every month and I told him yes, so I guess he has it on reorder and I would guess by his question I am one of his only customers to need DHE in ampules.

    Grrrr to the insurance (though I get their reasoning), but a grrrr also to the companies that make it difficult for a patient to get the treatment they need. I would also like to go back and find out just why it’s so expensive for insurance to cover triptans too – what is it about these meds that causes them to be so high in price? Even I was limited to 4 generic Imitrex/mo, and it only cost me $6! So I know the insurance cannot be paying that much for them, unless their pool of patients taking it is just so much greater since it is cheaper. I can see that.

  • Cathy Frost
    8 years ago

    I had this issue with Relpax; which works pretty well for me. My insurance would only allow 9-pills per month. Not only that, but being a “brand name” made it more expensive. So, it hurt in two ways; not enough to last a month and the expense. I have a pretty good doctor who believes in having a back-up medication. So, I am not left with nothing, but naturally the one that works the best is harder to get.

  • Karen Stanley Haack
    8 years ago

    They didn’t fill Sami’s Imitrex until she was 18 and it made her sicker then a dog. She took it once and refused to take it ever again….some of those migraine pills are pretty horrible.

  • Betsy Schornhorst Dean
    7 years ago

    The same thing happened to my daughter. She refuses to ever take it again. Her father has had success with it and has attempted to get her to try it again. She said no way!!

  • Laura Kincaid
    7 years ago

    I had a bad reaction to the Imitrax too. Zomig ZMT (orally disentigrating tablets) worked well, as does Relpax.

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