Health insurance coverage can be confusing. Here’s a breakout of different ways insurance companies pay for medications, including those for your migraine.
Understanding your health insurance coverage
Many insurance companies pay, or “cover,” the cost of prescription medications. If your insurance plan does not cover medications, you may have a separate prescription drug insurance plan.
Every insurance company has a list of medications it pays for. The list is called a “formulary,” or drug list.
How the insurance formulary works
Insurance companies usually divide a formulary into several groups, called “tiers.” For example, the formulary might have Tier 1, Tier 2, and Tier 3 medications. The insurance company might pay the whole cost for Tier 1 medications, part of the cost for Tier 2 medications, and nothing for Tier 3 medications. Or they might require you to try Tier 1 and Tier 2 medications before they consider paying for Tier 3 medications.
For all medications, you pay the rest of the cost after the insurance company pays its part. Your part of the payment is called a “co-payment” or “co-pay.” This might be nothing, very little, or a large amount.
An insurance company might also limit the amount of medication they pay for each month. If you need more than that amount, you may have to pay for the extra amount yourself. Also, healthcare professionals are able to appeal for a quantity override.
Getting a discount on your prescriptions
Several companies offer discount prices on prescription medications. Check with your health insurer or healthcare provider for manufacturer or online options for filling any prescription.
Generic and brand-name medications
A “generic” medication is not a particular brand. It is usually less expensive than the brand-name version of the same type of medication. Your co-pay for a generic medication might be low, or the medication may even be free.
Often, generic medications work just as well as brand-name medications. So if a generic version of your medication is available and works well for you, you may be able to save money. But if the generic version does not work well for you, you might need the brand-name version. If so, you will probably have a higher co-pay, or the company might ask you to try the generic version or a different medication. If those do not work, they might then pay for the brand-name version.
Why does the formulary matter for migraine medications?
When you have migraine, you might need to try several different medications until you find what works. You might need to take more than one medication—for example, one medication to prevent migraines and one or two to stop migraines (“rescue” medications).
Your insurance company might pay different amounts for these different medications. They might not pay for some at all. Or they might want your doctor to write a letter saying why you need the more-expensive medication. Get more tips on managing your insurance coverage for migraine medications.
Formulary list for common insurance plans
Below are links to the prescription drug formularies for some major insurance companies. You should know that these lists usually change every year. So it’s a good idea to check the date on a formulary and call your insurance company if you have any questions.