Migraine

I am having trouble getting the amount of migraine drugs my neurologist prescribed from my insurance company. They are using as a reason that it exceeds FDA dosage recommendations. My doctor says this is BS, and has sent numerous pages of my medical history.

Is there anything I can do or say on appeal? Anyone I can speak to at FDA or get some written info regarding this topic?

Thanks for any suggestions.

Which drug is it? If it is your abortive - they limit how many you can get in a months time. The only alternative is to appeal or have your doctor script different ones (if more then one works for you).

Check in your policy - most are online now with your drug info and what is covered as far as dosage - it would tell you right there.

Your doctor can always write a letter of medical necessity to your insurance stating you must have said drug in order to live as pain free as possible.....

Hope this helped!

Welcome Shaz.

Blue Cross Blue Shield was one insurance company that was bad for limiting triptans. My migraine MD pre authorized an amount per month more than BCBS was giving.

Like Eileen said, have your doctor contact your insurance; the insurance is making medical decisions for you, overriding your MD.

quote:

Originally posted by Shaz:
I am having trouble getting the amount of migraine drugs my neurologist prescribed from my insurance company. They are using as a reason that it exceeds FDA dosage recommendations. My doctor says this is BS, and has sent numerous pages of my medical history.

Is there anything I can do or say on appeal? Anyone I can speak to at FDA or get some written info regarding this topic?

Thanks for any suggestions.

Welcome to the discussion forum Shaz.

Deb and Eileen have given you great information. It is disgusting that insurance companies seem to be practicing medicine these days.

Let us know what else we can do for you.

To All,

My doctor has already appealed by sending them pages of my past and current medical history, twice because they claimed they never got it. that wasn't enough, so he sent more into Then he called.

Now I am going to appeal myself. I spoke with someone at FDA who said they do not decide what quantity a person should have; that it is up to the doctor. he also said that insurance companies use that excuse frequently because they don't want to pay. Unfortunately he wouldn't give me his last name. However I am going to write a letter quoting what he said, and also tell them I will file a complaint with the State Insurance Commission. It seems to me that since they gave me the quantity I needed last year, they can't use FDA dosage recommendations to limit me this year.

If anyone knows of any other ammunition I can use, please let me know.

Thanks.

Hi Shaz,

I know you said your doctor has sent your history and records but that is not the same thing as a letter of medical necessity. Did he include this when sending the records or just send your records?

Hello Shaz!

Boy, do I understand what you are going through. My insurance, Anthem Blue Cross/Blue Shield, limits me to a package of 9 Imitrex 100 mg tablets per month. When you are having migraines on a daily basis, that doesn't even begin to cut it. My doctor also prescribes Imitrex injections, and I can get a total of four shots per month (in addition to the tablets). I haven't tried to appeal the insurance company's decision, because I have had somewhat of a remission with my migraines. Now what I do is get the allowed amount of Imitrex every month, whether I need it or not. This has allowed me to "stockpile" my migraine meds, in the event of recurring migraines, which unfortunately, I started getting again just recently.

I do believe I know the cause of my new migraines. I have been prescribed Vicodin for a broken leg, and it is just awful. The Vicodin gets rid of my leg pain, but gives me migraines. I am so glad I am just about done with it, because I would rather have pain in my leg than have a migraine. It's just a good thing I do not have to take Vicodin on a regular basis. I couldn't stand the migraines all the time.

I agree with what someone said about getting a letter of medical necessity from your doctor. I had that done for Protonix, a med for acid reflux, that is usually only prescribed for short-term periods of time. My doctor wrote a letter, stating that I need it for the long-term, and now my insurance covers it every month. This is not the same as migraine medication, but I wanted to let you know that having your doctor do a letter of medical necessity can work.

I also concur with what someone said about having your doc prescribe a variety of meds for migraine. In addition to the two types of Imitrex, I take Propranolol and Cymbalta, as preventatives for migraine. The Cymbalta has been a double godsend, as it works for migraines and depression.

Best of luck to you. Let us know how things turn out for you. Your victory is a victory for all of us!

Kay

I feel your pain (no pun intended).

I often juggle between Maxalt & Imitrex. Trying to get by & double up my supply is practically impossible. If Walgreen's refills my maxalt today, and I drive down the street to CVS to refill Imitrex - they know & won't refill the imitrex. It's always a catch 22 situation.

Part of the doctor's creed is "... first, do no harm...", ... it seems the insurance company's creed is "First, do no good ..."

Hi, pugster! Welcome to the forum family!

Pugster,
May I ask what insurance you have? Most will let you be treated by 2 different doctors for migraine and fill more then one triptan script in a month time.....

I understand your reasoning for the flip flop with filling scripts by different places - but it can also hinder you as well. It is to your benefit to always get your perscriptions filled at the same place. Then they have ALL of your history - not just some of it. It helps with other drug interactions as well as potiential problems that may arise.

It's not really the pharmacy that is ok'ing the scripts - it still has to go through your insurance - if they are letting you fill both at two different pharmacies - then you should be able to fill them both at the same one. Your insurance keeps records of what all you have filled - so they know you just had Imitrex filled up the street a day before - they won't let you get the Maxalt if you are not allowed to get it per your plan.

Hope this makes some sense as I was kinda rambly.....

quote:

Originally posted by pugster:
I feel your pain (no pun intended).

I often juggle between Maxalt & Imitrex. Trying to get by & double up my supply is practically impossible. If Walgreen's refills my maxalt today, and I drive down the street to CVS to refill Imitrex - they know & won't refill the imitrex. It's always a catch 22 situation.

Part of the doctor's creed is "... first, do no harm...", ... it seems the insurance company's creed is "First, do no good ..."

quote:

Originally posted by Nancy Bonk:
Hi Shaz,

I know you said your doctor has sent your history and records but that is not the same thing as a letter of medical necessity. Did he include this when sending the records or just send your records?

I'm not sure what a letter of medical necessity is, but my doctor isn't big on writing letters. He usually sends what's already on his computer. It's very hard, between the doctor and the 1-person office staff, to get these things done, or to even find out what has been done. He did call them, and they claim they have no record of that. The last thing I did was send the doctor a sample letter from the Medicare Rights Center's lawyers for an appeal. But I don't know anything was done on the doctor's end. Another obstacle is that I have emotional problems that make it impossible for me to stay on top of everybody. A friend who had trouble getting her MS meds said I just have to keep calling and asking for supervisors until I get a person with some authority and an extension number and keep bugging that person. But so many days I can't even talk to people about normal everyday business matters, or even talk to my friends. I have problems calling the doctor's office because a couple of years back I kept bugging my doctor about my hospital admission (some aspect of it) and he stopped replying altogether and got very annoyed with me. I have to walk on eggshells, or at least that's how I feel.

thanks to everyone for your suggestions.

How do I reply to a specific person?

To Eileen: The quantity i need exceeds the dosage recommendations and the policy benefits. Though I use two different drugs (migranal & amerge) I still can't get enough to relieve daily migraine, and none of the preventitives have worked out for me.

And my doctor is kind of resigned regarding insurance companies.

It all aggravates my emotional problems with then paralyze me and I can't keep dealing with everyone involved in the process.

What are you on for preventive measures? What have you tried? With so many different options out there - maybe it's time to try a different preventive?

I'm so sorry that your migraines are so bad right now. Have you ever tried Imitrex as an abortive? I know with my insurance plan, Imitrex is the abortive I can get the most of (16 pills I think). Do you have a copy of your percription coverage? It should tell you there what the dosages have to be......maybe a different triptan would work????

I hate the medical "red tape" and hoops you have to jump through just to try and get yourself to have "ok days" much less live a normal life - I really don't think we are asking for too much here!

Also - I understand if you like this doctor and please don't misunderstand where I am coming from on this. But if they are unwilling to try and work with your insurance to get you what you need (and let me tell you, a lot of dr offices are!) maybe you may want to find another doctor? Just a suggestion honey - If it means the best possible health for you.....That is what is most important here.

Hope you are feeling better soon!

Really? I just got bcbs and thaey said they would give me 54 for 90 day supply. I take Frova. And they said the co-pay was $10.00 I will believe it when I see it. I will let you know. Mabey it depends on the policy you buy?

quote:

Originally posted by DebHOST:
Welcome Shaz.

Blue Cross Blue Shield was one insurance company that was bad for limiting triptans. My migraine MD pre authorized an amount per month more than BCBS was giving.

Like Eileen said, have your doctor contact your insurance; the insurance is making medical decisions for you, overriding your MD.

quote:

Originally posted by Shaz:
I am having trouble getting the amount of migraine drugs my neurologist prescribed from my insurance company. They are using as a reason that it exceeds FDA dosage recommendations. My doctor says this is BS, and has sent numerous pages of my medical history.

Is there anything I can do or say on appeal? Anyone I can speak to at FDA or get some written info regarding this topic?

Thanks for any suggestions.

I had Pacifi care last year. They were giving me the runaround about paying for my DHE 45 injections. So my husbands company had an insurance specialist in their corporate office. She helped me get my money. She wrote the ins co a very nasty e-mail and forced them to pay me. She also called the ins for me. It took me almost a year of trying on my own, then after contacting the corporate office I had the first check in about 30 days. It was 1200 that I had already paid, I had submitteed to ins for reimbursment.

quote:

Originally posted by Shaz:
To All,

My doctor has already appealed by sending them pages of my past and current medical history, twice because they claimed they never got it. that wasn't enough, so he sent more into Then he called.

Now I am going to appeal myself. I spoke with someone at FDA who said they do not decide what quantity a person should have; that it is up to the doctor. he also said that insurance companies use that excuse frequently because they don't want to pay. Unfortunately he wouldn't give me his last name. However I am going to write a letter quoting what he said, and also tell them I will file a complaint with the State Insurance Commission. It seems to me that since they gave me the quantity I needed last year, they can't use FDA dosage recommendations to limit me this year.

If anyone knows of any other ammunition I can use, please let me know.

Thanks.