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8 Ways to Manage Insurance Triptan Limits

insurance_triptan_limitsAs expected, none of you were surprised that people with migraine don’t take triptans for every attack. Although there are many reasons for this, insurance triptan limits keep most of you who commented from getting enough meds to last the month. If you’re in the group whose doctors would prescribe more*, but your insurance company won’t cover them, here are some ways you might be able to increase the number of triptans you get each month. The first four can be done at no additional cost to you; the last four will cost additional copays or have an out-of-pocket cost.

1. Try filling a higher quantity prescription: Not all insurance companies have limits. On an old insurance plan, I was able to get 60 tablets a month for the cost of two copays. Coverage like this appears to be more common with company insurance plans, rather than individual ones, but it’s always worth a try.

2. File an insurance appeal: Insurance companies have a process for doctors to request on override on medication limits. Call the company to find out exactly what information they need and provide it to your doctor. Your best bet is to only ask for a small increase in the number of meds each month. My doctor requested 30 and my insurance company told me they would probably have approved 12, but 30 was way too many.

3. Split pills: Some triptans can be split. Whether or not this will work for you depends on the drug itself, your dose, and your other health requirements. Do not do this without first consulting your doctor!

4. Use tablets: Injections, nasal sprays, and dissolving tablets cost insurance companies more than tablets and are often more limited in quantity. If triptan tablets work sufficiently quickly for you, check to see if your insurance company will allow you more tablets than other forms.

5. Double the copay: Ask your insurance company if you can get the same prescription twice with two different copays. If you normally get six triptans for $15, you might be able to get 12 for $30.

6. Use two different triptans: If you can’t get the same prescription twice, you might be able to get two different kinds of triptans with two copays. In my information survey, this seems to be the most common allowance that insurance companies make. (Talk to your doctor about dosing. Most say to not take two different triptans within a 24-hour period.)

7. Use two different delivery methods: A reader said that her insurance will cover prescriptions for both Zomig tablets and Zomig nasal spray each month. The same would work for others with multiple delivery methods, like Imitrex (sumatriptan) injection and tablets or Maxalt (rizatriptan) ODTs and tablets.

8. Pay cash (with a discount): If your insurance company won’t budge and it’s within your budget, you can pay cash for additional triptans. You pay per pill and price depends on which drug you get and which delivery method you use. I use a drug discount card (GoodRx) or go through HealthWarehouse.com for the lowest prices. Sumatriptan (Imitrex) tablets are by far the least expensive at $1.44 per pill on HealthWarehouse.com and $1.60 per pill through GoodRx (as of today, prices fluctuate). You can check prices for both online. Readers have also recommended Costco.

How do you manage insurance triptan limits?

*Medication overuse headache (a.k.a. rebound headache) is a serious risk that can increase attack frequency and make migraine even harder to treat. Only an extended period without the problematic medication and close consultation with a knowledgeable doctor can determine whether you are at risk.

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Cefaly Insurance Coverage Update

“Is Cefaly covered by insurance?” is the question I’ve been asked most since the device was approved. The answer is probably not, but your insurance company may cover it as they would any TENS unit.

Cefaly does not currently have a procedure code (also called a CPT code), which is required for an insurance company to cover any medical device or procedure. A company representative told me FDA approval is the first step in the long process of getting a CPT code. They expect it to be one to two years before Cefaly has a code.

Hope is not lost! Some migraineurs have found that their insurance companies will cover Cefaly the way they would any TENS unit using an established code for those devices. Google tells me those are E0720 for a two-lead device and E0730 for a four-lead device. The problem? Cefaly only has one lead, which may trip up some insurance companies.

HomeCare, a magazine for the home medical equipment industry, says that to have a TENS unit covered for chronic pain, your doctor must submit a statement of medical necessity and “must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time. The physician’s records must document a reevaluation of the patient at the end of the trial period and indicate how often the patient used the TENS unit, the typical duration of use each time and the results.” Unfortunately, the article also says TENS units are rarely considered medically necessary for headache disorders. (This is general industry information. What you encounter with your insurance company may be different.)

Don’t give up without checking with your own insurance company. Enough migraineurs have received positive responses that it’s worth a try. Please let us know if you have success and, if possible, which code your insurance company is using.

Update on Cefaly availability: As of April 9, 2014, the order page of Cefaly’s U.S. website says, “Order intakes on hold for a week because of limitation in the supply chain.” This notice apparently went up today, so I hope that means you’ll be able to order from them next week. I’ll keep an eye on the site and let you know if anything changes.

April 15, 2014: Cefaly has removed the “not currently taking orders” notification from their website. They appear to now be shipping previously ordered products and taking new orders.

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Tips for Getting Onto the Federal Health Insurance Marketplace

After years of eagerly awaiting the Affordable Care Act’s insurance marketplace, technical glitches weren’t going to deter me from finding out which plans would be available to me next year and how much they’ll cost. Tips for Accessing HealthCare.gov’s Federal Insurance Marketplace on Migraine.com outlines how I finally succeeded in reviewing health insurance plans after literally spending hours each day last week trying to access HealthCare.gov.

The most important tip? Use Internet Explorer! Despite trying Firefox, Chrome and Safari, Internet Explorer is the only browser that allowed me to access and complete the application and review health insurance plans.

If you’re chomping at the bit to learn what your health coverage might look like next year, check out all my suggestions on Migraine.com.

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Insurance Coverage of Triptans

Insurance is an ongoing nightmare for practically everyone. If you need more triptans (a common type of migraine abortive) a month than your plan allows, you’re in for a real hassle. Without insurance they are, of course, mighty pricey.

Kathy, a reader, is faced with a new bureaucratic hurdle that I’ve never seen before. Her story follows. She’d appreciate any advice you can give.

I just had to share this with someone that could understand, and maybe you have some suggestions as to whether anything can be done. I was just informed by my insurance company that I can now only get 4 Maxalt tablets at a time. I can get 8 per month (down from the 9 per month it used to be) but I have to go in to the pharmacy TWICE per month. Maxalt is the least troublesome of the triptans for me and enables me to keep working with a migraine. My migraines usually last 3 days (requiring 6 Maxalt) and CAN last 5 – 6
days. It is so infuriating that an insurance company can do this.

Their explanation was that studies have shown that most people (?) only refill their prescription of 9 tablets once every 3 months. 38% of the prescriptions are never refilled. So they decided that 3 pills is a 30 day supply. Have you ever heard of anyone being successful in fighting something like this? Any ideas on what to do?

Even if you don’t have suggestions for Kathy, eave a comment with your story — whether good or bad — about getting the meds you need. I and other readers will certainly benefit from your experience.

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News From the American Headache Society’s Annual Meeting

If I wait to write about news from the American Headache Society’s annual meeting in depth, it may never get posted. So here are the headlines and links to AHS’s press releases.

Insurance, Cost Issues Prevent People From Treating Migraines

Insurance companies often limit the number of migraine pills people are allowed each month, so many sufferers forgo taking the medication when they need it because they’re afraid of running out. . . .

That translates into many people unnecessarily living with potentially disabling migraine pain and suffering poorer quality of life than they would have if they took their medication when needed.

Killer Headaches Play Starring Role On The Silver Screen, But Don’t Reflect The Real World

Horrendous headaches make fabulous movie plot devices and are often the result of such dramatic situations as a tumor, toxic poisoning or device implanted in the brain, rather than something as banal as a migraine. . . .

“Yes, we know movies are fantasy, but they also are very effective at formulating public opinion. So many people already worry about what causes their headaches and this is not a good way to reassure them.”

In the real world, the vast majority of head pain is “primary,” meaning the cause typically is migraine, tension or cluster headache. Unlike in the movies, headaches are far less often due to “secondary” causes, such as head trauma, stroke, aneurysms, infection or tumors and never – at least to the knowledge of medical science – by a brain-control device.

Three-Item Questionnaire Helps School Nurses Identify Students With Migraines

A simple questionnaire can help school nurses identify students who get migraine headaches, a problem that affects one in 10 children and teens but often goes undiagnosed. The three-question Pediatric and Adolescent
Migraine Screen (PAMS) is an accurate measurement of migraine that easily can be used by school nurses. . . .

“Although PAMS is not a final diagnostic tool, using it to screen and possibly refer children for appropriate diagnosis of migraine can greatly improve these kids’ quality of life, including their ability to participate in school, sports and other extracurricular activities,” said Dr. Kabbouche.