Is anyone experiencing supply limit on triptans with their insurance company? United Healthcare now limits the supply for all triptans to only 4 per month, no matter the drug (brand or generic). How can this be best medical practice? Sometimes i need more than one pill for a migraine and certain months depending on the weather and stress (my triggers) I may have more or less than 4 migraines. Is anyone else encountering the same problem? Is this a recent change? My former health plan (Aetna) provided 9 pills per month. HELP!
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Q: Is anyone experiencing supply limit on triptans with their insurance company?
Answers (21)
12/29/11 11:05pm
Hi politichickdc,
Four per month is a bit drastic, have you tried an appeal? There is another reason triptans are limited; abortivemedication such as triptans are only to be 2-3 days a week.
If we take Migraine abortive meds such as triptans or any kind of pain med more than two days a week, a big part of the problem may well be medication overuse headache (MOH), aka rebound. See Medication Overuse Headache - When the Remedy Backfires for more information on this. If you're in an MOH situation, nothing you take is going work, neither prescription nor "natural" medications nor over-the-counter. If that's the case, you need to work with your doctor to stop the medications causing the problem.
Anyone who has three or more Migraines a month needs to be talking with their doctor about prevention. There's growing evidence that Migraine is a progressive brain disease. A recent study showed that Migraines can cause brain damage, and that people with three or more Migraines a month are more susceptible to this damage. For more information, see Is Migraine a Progressive Brain Disease?, Yes, Migraines Can Cause Brain Damage, and Migraine with Aura Linked to Late-Life Brain Lesions.
Good luck
Nancy
12/29/11 3:16pm
This is very common. For a short while I had Pacific Care and they also limited me to 4 Triptans a month and my doctor and I went through all sorts of hoops trying to get them to approve 9. He'd have to send in (and I'd have to wait for) a "Prior Authorization Approval" EVERY SINGLE TIME I went to get a refill on what I thought was an already approved order! I'd come in and find they'd only approved 8 or 6, or just arbitrarily given me 4 again. It was absolutely maddening. I ended up going back to Kaiser, and thank God, found a doctor there who was willing to work with my migriane specialist (who was outside the Kaiser system) and this doctor approved my 9 triptans a month. This is still how I get them.
12/30/11 12:03pm
politichickdc,
Oh, yes, and it's all about $$ and the deals the insurance companies make with the various pharmaceutical companies to get good prices on all of the meds the companies make.
Let me give you an example - I was using Axert, and was limited to 24 tablets for 90 days. Then I got a letter from my insurance company informing me that the were no longer going to pay for Axert without my doctor jumping through hoops, but they would pay for Maxalt or Relpax. So, my doctor wrote me a prescription for 36 Maxalt-MLT tablets for a 90-day supply. The insurance company covered it - 12 tablets more than they had covered when I was taking Axert. To add to all of this, when I went back and looked at what the insurance company had paid for my Axert prescription compared to what they're now paying for my Maxalt prescription, they're paing $6 per tablet more for Maxalt. It was explained to me that it has to do with which companies will give them the best prices overall on all of their products, not individual products.
Insurance companies don't seem to care what our doctors feel is the best treatment for us. It's all about the $$.
Teri
1/11/12 9:36am
We have BCBS Blue Access in Indiana. For my generic Sumatriptan 100mg pills the RX is for 9 pills and I'm only allowed 1 refill a month. The same with my generic Sumatriptan 6mg injection. I can only get 2 pkg per month for a total of 4 injections per month. I have been suffering from intractible debilitating migraines for almost 2 years. I have to rely on my backup rescue meds which my Dr is trying to find a better acting preventive and a better backup one. I don't think insurance companies should have the right to limit your refills like that. If you suffer 2-3 migraines on a weekly basis (genetic, climate, hormonal changes, stress, etc) you should be able to refill them as needed. Insurance companies are not doctors. Your doctor knows best what your limit of a medication should be.
1/ 2/12 2:03pm
Yes, yes, yes I take Frova 2.5 my insurance only allows 9 pills per month
although after calling the drug company, they actually admitted patients use
this medication daily. I take this medication on a 24 hour cycle, without it
I cannot function. My doctor wanted me to start reducing the pills, it worked
for a while, but the headaches return and I MUST function. Therefore I buy
the rest of my medication out of pocket. Very expensive, I just started an
investigation for the surgery to cut all facial nerves. I also have bad neck pain
along with the headaches.
1/ 2/12 3:00pm
You take a triptan daily ? Are you experiencing rebound headaches ? I have chronic migraines myself and am supposed to be starting a round of Botox this month. Have you considered trying Botox ? greg
1/11/12 9:43am
It's very hard to get insurance companies to even cover the cost of Botox. I had mine done in December 2010. The insurance company approved it, I had it done, then when it came time for the insurance company to pay they denied it. We fought for quite a while and even filed a complaint with the Indiana Dept of Insurance and they said BCBS Blue Access of Indiana acted within their guidelines-they consider injections like that as "non-preventive" but they consider a flu shot as "preventive". EXCUSE ME, but the idea and reason behind the Botox was to prevent FUTURE migraines and with that less use of triptans and a host of other meds to try to prevent and abort. The doctor clearly coded the procedure as medically necessary and submitted a host of documents to back their claim to prevent future debilitating attacks. Still was denied and we were stuck w/a $1400.00 bill to pay out of pocket. Oh, they said that would go towards my $2500.00 per yr deductible. I've been off work because of these stupid migraines since 5-10-10. Who can afford to pay for Botox out of pocket like that? Insurance sucks! What good is it really?
1/ 5/12 12:11pm
Cindy - you may hear success stories about people having this surgery done but I suspect they will all come from the doctor. I would strongly advise against this surgery. I had it done by Dr. Guyuron in Cleveland, OH. Sometimes, you hurt so bad you want to believe that things this drastic have to work. They don't all the time, but you'll never hear about the failures. I paid $14,000 out-of-pocket for this surgery. Two parts of it were cutting a trigeminal nerve at each temple, two nerves along my hairline, and two occipital muscles in the back of my neck. Now I suffer the repercussions from that. Surgeries like this just don't make everything go away. My neck is weaker now and has blood flow problems that result in the muscles painfully burning and pulsating up the back of my neck. It's all connected. The blood from those muscles pulse up into the side of my face and jaw. Since there were key nerve endings that were cut, the blood has no where to release which results in tension and migraine headaches. My scalp is super sensitive and since the nerves in my hairline were cut, my forehead throbs and the pain builds up in my eyebrows and behind my eyes. It sounds weird but my eyebrows hurt to the touch. This will never go away. The surgeon's office followed up with me once after the surgery. When they realized it wasn't successful, I never heard from them again. That surgery may take away one pain but it brings with it new ones. I would not do it again if I had the choice. I remain a mystery to every specialist I see (neuro, chiro, massage, etc.) because they are dealing with things unknown to them. I always get strange looks when I tell them about this surgery. That's my experience for what it's worth. Just make sure you make an informed decision. Good luck.
1/10/12 7:41pm
I hope this answer isn't duplicated, but I was very interested in your reply
because I also was to see Dr. Guyuron relating to a consult on the surgery.
I have already seen Dr. Reed. She suggested therapy, but my insurance
only covered six treatments, some of it actually made me feel worse--- Light
headed and dizzy. I used to live in Cleveland, but not live in another part
of OH, where the doctors, just do not deal that much with chronic migraine
patients.
1/10/12 7:41pm
I hope this answer isn't duplicated, but I was very interested in your reply
because I also was to see Dr. Guyuron relating to a consult on the surgery.
I have already seen Dr. Reed. She suggested therapy, but my insurance
only covered six treatments, some of it actually made me feel worse--- Light
headed and dizzy. I used to live in Cleveland, but not live in another part
of OH, where the doctors, just do not deal that much with chronic migraine
patients.
1/10/12 8:19pm
Dr. Reed is my neuro. I live in Tampa but my family is in Canton so I fly there once a year to see her. I heard about Dr. Guyuron on a news report about 6 years ago. I'd be more than happy to share my experience with you. It doesn't sound like you've had a consult with him yet but it would do you good to hear the other side of it - mine. He certainly wasn't interested. If you want to e-mail me, I'll e-mail my phone number to you (klameier@verizon.net).
1/ 2/12 4:03pm
4 per month?!?!? That's amazingly low. Wow.
Will they raise the limit if your doc writes an appeal?
It's amazing what these insurance companies try and get away with sometimes. I can get 6 Zomig NS, or 12 generic naratriptan, or 9? tabs of frova- all based on what it costs the insurance company.
I happen to have a Rx for all three... Unfortunately, the generic narattiptan doesn't work for me. (I miss my Amerge!!!) and with my doctor's staff's help, can fill both the Zomig NS and the Frova- -Used VERY differently for me, so it's not like I'm totally hording.
I know I'm lucky in that I can do this. However, it does raise my Rx cost/month.
1/ 2/12 8:30pm
I take relpax. It comes in 6 pills per month. My Dr wrote for 9 they will only pay 4 6. I have also taken axert and maxalt and zomig. Those all had limits to. If I had 2 dif precriptions they will fill for them as long as they don't exceed amount
1/ 3/12 10:41am
Yes, United Healthcare has had limits on triptans for years. In the past few years (at least eight or so), in order to get more than the four migraines allowed per month, the doctor needs to send a letter to United Healthcare for a pre-authorization and explanation, why you need more than the allotted amount. This needs to be done at least every six months by your doctor. Even then, they usually only will allow eight tablets of a tripton medication. I was notified in November, that United Healthcare will no longer pay anything, for my Zomig,(even after my deductable of $7000.00) nor will I be able to use my health savings account to pay for it! The only way to have them pay any toward it is to have another letter sent by my doctor, stating why I cannot change to another triptan medication, and receive my prescription by mail through Medco! United Healthcare sent a letter telling me to change medications if I want any of it covered. Soon I believe, they will not pay for any migraine medications. I have been dealing with them for many years, MANY MANY letters, and months of suffering through migraines without medications because of the paperwork. Now, I make sure, my doctor gets all the requests from them ASAP so there is no delay in processing the prescription. You have to be very persistant to get your medication, which is unfair. They make you feel like a drug addict when you go to the pharmacy to pick up a tription and it is denied over and over again!
2/26/12 1:00pm
Hi Trish, I have to go through the same exact nightmare with Medco. I think it is degrading and outrageous to recieve these letters from a mail order company telling "me,"-- a lifelong migraine sufferer, who has tried every single migraine drug out there, to "switch" to a lower cost of medication or else not be covered, as if this were as simple as switching to a lower brand of toilet paper!
Medco is the worst! And (I dont know if you received this or not), I received a letter from them 6 months ago, telling me that they were processing refunds for miscalculating the "savings" of using Medco, BUT I never received any refund and they have ignored 3 letters from me regarding this!
1/ 5/12 11:39am
I am now (as of January 1) on Medicare and the drug plan I chose doesn't even have Triptans on their formulary. Luckily my headaches are down to one or two a month and I have been stockpiling Relpax on the old plan, so I'll deal with that when I come to it later. It's a new world out there.
1/ 5/12 11:47am
Absolutely! Four years ago Blue Cross Blue Shield began limiting me to one prescription of one triptan once a month. I had to choose one and couldn't change. I chose Relpax so for the last four years, they've allowed me (6) 40 mg pills once a month. I got a letter from a BCBS doctor on their staff saying this was best for me. I freaked. So, at the times when Relpax doesn't seem to be effective, I can't use Maxalt or Treximet, both of which have also worked for me in the past, because BCBS won't pay for them. Luckily, my neurologist submits paperwork every year asking for an exception to this rule so I can get 12 pills a month instead of 6. This costs me $307 each month. So stupid on their part because whether I need the Relpax or not, I'm always going to fill the prescription every month just in case I have a bad streak. Plus, I'd probably take even less if I could use one of the other triptans. They've totally got me backed into a corner. I can't even think about going to another neuro. Can you imagine trying to explain this, get what I need, and making the transition with BCBS with a new neuro? It would be a complete nightmare.
1/11/12 9:48am
I hate BCBS. They are a pain in the a_ _!!!! They should not be allowed to limit the amount of medicine you get a month, especially if you have a note from your neuro. Insurance companies need to get it thru their brick thick skulls they are not doctors and butt out of it! They've gotten way out of hand-like a dictatorship. I get mine filled every month to have on hand just in case and hopefully have a little extra on those really bad months when they are needed.
1/ 5/12 12:04pm
Have you tried getting pre-certification from your physician? I used to only get nine until he completed a pre-cert form for the insurance company and they doubled my limit to 18. It's really unfair given the fact that there are times when you need more than one dose.
1/ 5/12 12:10pm
YES! So frustrating!!! For me, the ONLY medication that works (like a charm, thankfully!) is imitex (even the generic). My insurance limits to 3 per month and I likely get 4-10 migraines per month depending on weather and stress. They give bottles and bottles of fiorinal with codeine but I don't like taking that due to the temporary relief and frequent rebound (as well as inability to drive, work, or be a mom!!). I hope the insurance rethinks this plan, it makes NO SENSE!
1/ 5/12 12:16pm
YES! So frustrating!!! For me, the ONLY medication that works (like a charm, thankfully!) is imitex (even the generic). My insurance limits to 3 per month and I likely get 4-10 migraines per month depending on weather and stress. They give bottles and bottles of fiorinal with codeine but I don't like taking that due to the temporary relief and frequent rebound (as well as inability to drive, work, or be a mom!!). I hope the insurance rethinks this plan, it makes NO SENSE!
1/ 5/12 3:05pm
My insurance provided only 18 Zomig per year. An appeal from my doctor's office netted 9 per month. That still was not enough. I think it was odd that I had to fight with them for pills, but they paid 100% for a sleep study and did not require precertification . I found that I have severe sleep apnea. The CPAP machine has eliminated the night time headaches, which were my main problem.
Another avenue might be to try another brand. My secondary insurance allows 9 Imitrex per month without approval. Between Zomig and Imitrex, I was OK.
1/ 5/12 7:21pm
Either my insurance is great or it is in the hands of my dr. I had this problem when my GP administered the meds but now that I am going to a headache specialist I get what I need!!
1/ 5/12 8:33pm
This is not a recent change. I thought that is why I pay for health benefits and co-payments. My experience is with Keystone and Blue Cross Insurance companies. Both Insurances have extremely limited the quantities without regard to the doctor's prescription. I had the same problem with Imitrex, before it stopped working. I get 12-20 migraines a month. Zomig is the only thing that currently works for me. However, I am only able to get 9 pills for a three month period. If I purchase on a 30-day I am still limited in quantity and the cost multiplies.
The insurance companies require a patient to see a doctor and get the prescription (based on health issues and necessity). Should you be lucky to have a doctor who is willing to complete the medical necessity forms (insurance requirement) the Insurance companies have not and are not willing to fill the prescription the doctor wrote. I think it basically comes down to $$$$. You will have to pay out of pocket again and at the Insurance premium prices if you can obtain anymore. It has nothing to do with how sick you become with the migraines. I have tried to work with BCBS but their only suggestion is to contact the manufacturer to see if they will provide the drug for free. You should try this avenue. Also, you should try to request a reconsideration through the insurance. I feel your pain! I just wish the Insurance Companies felt one migraine for each of us experiencing it. Maybe then they wouldn't limit the quantities.
1/ 5/12 9:24pm
Aetna insurance ca give 18 pill a month if your Dr call the insurance and make the recuest,
1/ 6/12 9:54pm
I have experienced the same problems all noted above. The only abortive medication that works really well for me is Relpax but I am limited to 10 pills a day but it was with a special note from my Doctor. In the Spring and early Fall I suffer more than 10 migraines a month due to barometric pressure changes in the weather and of course stress is always a problem but my MAIN problem is perfume and body lotions! So I suffer nearly every day. My Doctor put me on Inderal LA 80 mg. daily in addition to my daily 50 mg. Topomax and I've made a notiable improvement. I still get migraines and use nearly all 10 Relpax each month but I have found I don't run out like I did.
1/10/12 3:08pm
After Relpax and Maxalt stopped working, new Dr. put me on Trimetex (sp?), but Anthem Blue Cross wouldn't cover it w/o me trying Imetrix first, which didn't work for me a few years ago. I tried it again, wanted the Trimetex, but ABC said that I would have to pay $50/month, instead of $10 for Imetrix. I did some research online and found that the only difference between Imetrix and Trimetex is that the Trimetex has Aleve in it (or it's generic equivalent). So, I'm taking the Imetrix + Aleve, now. Much cheaper. Works about half of the time. And I'm only allowed 6 Imetrix/month by ABC. So I go between Excedrin and the Imetrix. Most importantly, I stay clear of foods containing perservatives, MSG, gluten, soy, etc. Also, physical therapist has greatly improved my posture (neck, especially) and that seems to have helped with the frequency of my headaches. Have to look for any way to relieve headaches.
1/10/12 8:56pm
Yes. My insurance company limits me to 9 tablets a month (Maxalt). So I have my Dr. write me a script for Frova, I get 9 of those a month. I know I can't take them together but with timing I can alternate but there are months when I have to get through with no triptans. No triptans, no work!!! Do insurance companies limit Diabetics and Heart patients their medications????
1/11/12 9:34am
We have BCBS Blue Access in Indiana. For my generic Sumatriptan 100mg pills the RX is for 9 pills and I'm only allowed 1 refill a month. The same with my generic Sumatriptan 6mg injection. I can only get 2 pkg per month for a total of 4 injections per month. I have been suffering from intractible debilitating migraines for almost 2 years. I have to rely on my backup rescue meds which my Dr is trying to find a better acting preventive and a better backup one. I don't think insurance companies should have the right to limit your refills like that. If you suffer 2-3 migraines on a weekly basis (genetic, climate, hormonal changes, stress, etc) you should be able to refill them as needed. Insurance companies are not doctors. Your doctor knows best what your limit of a medication should be.
1/16/12 11:22am
I completely understand your frustration. I had the same problem for a long time, causing me to jump through any hoop I could find to get more of my medication. I would ask the doctor for samples on really rough months, and I got to the point where I was splitting my pills in half just to have some relief on hand for later. It did not always work with half a pill, but sometimes it did. Some insurance companies will allow you to get more pills if your doctor writes a prescription saying you have a need for it. These are about the only solutions I have found. I finally got Cigna through my employer, which allows me 30 pills a month! I am not an abuser of these pills, mind you, but all of you with migraines know that when you feel it coming on, the worst thing you can do is wait to see if it goes away! Anyway, I hope this provides you some help. Good luck!
1/23/12 9:03pm
Hi! I have rx's for imitrex (9), maxalt (9), replax(6) and since last week treximet (9)and since they r all in different catagories, i am aloud them all but I had 22 migraines in december or rather 22 times I took these meds. Sometimes it only eases the pain for several hours and when its back i took more. I havent worked since the week before Christmas and my family is really suffering bc we r a 2 income family. Today the dr. said we r going to do botox on thursday and I am praying for some good results so i can get back to work and being a mom. All that to say, yall r right about pharmacies limiting our amount of meds!! I can get doped up on loritabs and get plenty but i just need some relief of all this pain.
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By politichickdc— Last Modified: 02/26/12, First Published: 12/29/11
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Four triptans a month? Wow, that is absurd. Doesn't surprise me with United Healthcare , they have a reputation for these kind of things. I guess I should consider myself fortunate that my BlueCross covers 12 a month. Interesting what you bring up about the Axert and Maxalt, Teri. BlueCross just stopped covering Maxalt (at about $38 a tablet retail) but is covering 12 SumavelDosepro (at $109 an injector, one dose). However, do not for a minute think these insurance companies are paying retail pricing. What they are paying your pharmacy is not unlikely their actual cost. They have more than likely struck a deal where money is rebated from the pharmaceutical manufacturer to the insurance company. This is common practice.