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Practice Matters: Wide Variation in Triptan Coverage Across Commercial and Government Health Plans

Bender, Eve

doi: 10.1097/01.NT.0000524839.20893.03
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In an analysis of formularies in New York State, researchers found substantial variation in the coverage and quantity limits for triptans for both government and commercial insurers. The results are generalizable to coverage in other states, independent experts said.

Insurance coverage of triptan medications varied widely between health plans and imposed quantity limits, step therapy, prior authorization requirements, and multiple co-payment tiers, according to findings published in the July 9 online issue of Headache.

“The complexity and convolution of finding and understanding much of the insurance information was a bit dismaying,” first author Mia T. Minen, MD, chief of headache research in the division of headache medicine at New York University Langone Medical Center, told Neurology Today in an interview.

Dr. Minen noted that given the overuse of opioids in the US, “key players might realize that they should work on improving access to non-opioid therapies... In addition, with the increasing likelihood of more expensive migraine medications coming to the market, such as the calcitonin gene-related peptide antagonists, insurance companies might decide to lower the barriers of these cheaper alternatives,” she said.

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Dr. Minen and colleagues examined triptan coverage by health insurance plans offering coverage in New York, including four commercial plans: Cigna, Oxford, Blue Cross, and Aetna; and for three government plans: MagnaCare, Healthfirst, and Medicaid.

Although the health plans were limited to those of New York state, Dr. Minen said that since the state features both rural and urban areas and is not an outlier in terms of socioeconomics. “We think that the results might be generalized with caution.”

The findings revealed that only four of 36 Medicaid plans covered a non-generic form of triptan. Patients receiving prescription drug coverage from commercial insurers were in general far more likely than patients receiving government coverage to have access to brand name triptans. The only exception was for zolmitriptan (Zomig) nasal spray, where there was no significant difference between commercial and government insurance coverage.

More than 80 percent of plans imposed quantity limits on 14 of the 19 formulations studied. In addition, the vast majority of the plans used tiers to allocate co-payment costs for the different medications. The tiers refer to the level of approvals, restrictions, and co-payments needed. Tier 1 is the least restrictive. Tiers higher up may require prior authorization/prior history of failing a lower-tiered medication and may cost more money for the patient.

Generic triptans, including generic sumatriptan tablets, nasal spray and injection; naratriptan; and zolmitriptan were almost always in tier 1, while non-generic triptans were most commonly found in tier 3. About 40 percent of non-generic triptans could be accessed only through step therapy — requiring that physicians prescribe lower-cost therapies that fail first before moving patients on to higher-cost therapies — compared with 11 percent of generic triptans.

While government insurance plans were found to not impose as many quantity limits with the exception of sumatriptan tablets, they were less likely to provide coverage for these medications in the first place, according to the results of the study.

According to the authors, some triptans listed in formularies were categorized as non-preferred or they required completion of prior authorization forms before a prescription was filled. “This creates extra work for physicians and has the potential to delay patient access to treatment,” they wrote. “This is concerning because migraine attacks can be variable, not just between individuals but within the same individual.”

The study found that both commercial and government insurers in New York provided access to a wide range of generic triptans, including non-oral formulations such as sumatriptan injection and nasal spray, but that access to brand name triptans was more limited: Commercial insurers were more likely to include brand name triptans on their formularies than were government insurers.

Patients in commercial plans were twice as likely to have access to frovatriptan, which is most commonly used to treat menstrual migraine. “This treatment disparity will disproportionately affect women of lower socioeconomic status, a group that is already medically underserved,” the study authors wrote in the discussion section.

The authors noted that the costs vary for a number of triptans, ranging from $12 to $120 in the United States.

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Richard Lipton, MD, FAAN, professor of neurology at Albert Einstein College of Medicine and director of the Montefiore Headache Center, said the study findings reflect his own experiences as a migraine specialist.

He noted that health plans vary in which of the seven marketed triptans they cover and in the maximum number of covered doses per month. “As patients differ in their treatment needs, it can be difficult to give patients the optimal drug in optimal quantities,” he observed.

Neurologists and headache specialists become very familiar with the formulary and number of triptans allowed per month for insurers in their states, said Randolph W. Evans, MD, FAAN, clinical professor of neurology at Baylor College of Medicine in Houston.

“The limit of number per state is arbitrary and unfair. Some plans only allow four tablets per month but we typically see patients with high frequency episodic or chronic migraine,” he told Neurology Today in an interview.

He added that while medical overuse of triptans can be a potential concern, “We have occasional patients who don't respond to other medications and safely and effectively take triptans more than two days per week and even daily in selected cases.”

Dr. Evans pointed out that “all triptans are clearly not the same, with variable efficacy, speed of onset, and side effects. Some patients also benefit from receiving different formulations for different attacks such as oral, nasal, and injectable.”

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•. Minen MT, Lindberg K, Langford A, Loder E. Variation in prescription drug coverage for triptans: Analysis of insurance formularies Headache 2017; Epub 2017 Jul 9.
    •. Wilper A, Woolhandler S, Himmelstein DM, Nardin R. Impact of insurance status on migraine care in the United States: A population-based study http:// Neurology 2010; 74(15):1178–1183.
      © 2017 American Academy of Neurology