Does Medicare Cover Sumatriptan?

Sumatriptan, which is also known by the brand name Imitrex, is prescribed to treat the symptoms of migraines. Although it doesn't prevent or reduce the frequency of these headaches, it's often effective in eliminating or mitigating the associated symptoms. Here’s what you should know about this common medication and the applicable coverage rules for seniors who have Original Medicare or Medicare Advantage. 

Does Medicare Cover Sumatriptan?

In its generic form, sumatriptan is relatively inexpensive and is covered by 100% of Medicare prescription drug plans.

How Much Do You Have to Pay for Sumatriptan Under Medicare?

Your out-of-pocket cost for the medication may range from nothing to $20, depending on your policy’s terms and the stage of coverage you’re in. If your plan has a deductible that you haven’t yet met, you may be responsible for the full cost of the drug. Although this deductible varies by plan, under Medicare rules, it can’t exceed $545 in 2024. However, depending on your plan, certain tiers of drugs may be fully covered, even if the deductible hasn’t been met. 

Does Medicare Have Coverage Limits for Sumatriptan?

Depending on your specific Medicare prescription drug policy, coverage limits may apply. To find out the details of your policy, check the terms of your contract or contact a plan representative.

How Does Medicare’s Prescription Drug Coverage Work?

Medicare beneficiaries can receive prescription drug coverage through either a Part D prescription plan or a bundled Medicare Advantage policy. 

Medicare Part D

Beneficiaries who are enrolled in Medicare Parts A and B may elect to receive prescription drug coverage through an optional Part D plan. Part D plan participants have access to any medication in their policy’s formulary, including generic and brand-name drugs. However, available medications and coverage rules can differ by policy, and plan availability may depend on the region where you live. 

Drugs included in a policy’s formulary are arranged into tiers, which dictate the cost to the beneficiary, with lower-tier medication typically priced less expensively than those in higher tiers. Although some drugs may not be included in a plan’s formulary and, consequently, aren’t covered by Medicare, medications that have similar uses may be available. However, beneficiaries may file an appeal if they believe a drug should be covered. Plans may also limit the number of pills that may be covered during a predetermined time frame.

Medicare Advantage

Prescription drug coverage is bundled into most Medicare Advantage policies and is mandated for special needs plans. However, if you join a Medicare Advantage HMO or PPO plan that doesn’t cover prescription medications, you can’t add on a separate Part D policy.

Similar to Part D coverage, Medicare Advantage plans use tiered formularies to determine the cost of prescription medications, and drugs in lower tiers usually cost less than those in higher tiers. These formularies typically vary by plan, and restrictions on the number of pills a plan covers may apply.

What Is the Medicare Donut Hole?

Medicare’s donut hole is a coverage gap that may impact seniors who have substantial prescription drug costs. During this time, Medicare may limit the amount of coverage for a medication, leaving beneficiaries responsible for a larger percentage of the cost.

You’ll typically enter the donut hole when the combined drug costs to you and your plan pass a certain threshold, which can change from year to year. In 2024, the threshold was set at $5,030. Seniors with high prescription drug costs may eventually pass through the donut hole into a catastrophic coverage phase. This typically occurs after a beneficiary has reached their plan's predefined limit for out-of-pocket costs.

What You Should Know About Sumatriptan

Sumatriptan belongs to a class of drugs known as selective serotonin receptor agonists, or triptans, which are used in the management of severe migraines. It may be prescribed as a standalone drug or as a combination medication that includes the pain reliever, naproxen.

How Sumatriptan Works

Migraine symptoms may occur due to a widening of blood vessels in the head. Sumatriptan addresses these symptoms by narrowing blood vessels, reducing inflammation and blocking pain pathways to the brain. The medication may reduce or eliminate pain, throbbing, nausea, sensitivity to light and other common migraine symptoms.

How Sumatriptan Is Administered

Sumatriptan may be prescribed as a tablet, nasal spray or injection and is typically taken at the first sign of a migraine. Although it may be administered via injection in a doctor’s office, it’s typically prescribed for home use.

The drug typically works within 2 hours. When taken orally, a second tablet may be taken if symptoms haven’t disappeared completely by then or return after that time frame. Before taking more than two doses, you should call your doctor to learn the daily limit of this medication. The drug should not be used for more than 10 days each month.

Potential Side Effects

Although many individuals tolerate sumatriptan well, some people experience common side effects, such as:

• Tingling
• Dizziness
• Tiredness
• Weakness
• Muscle cramps
• Nausea or diarrhea
• A warm or cold sensation

When to Seek Emergency Care

Individuals who take sumatriptan may experience more severe reactions. Seek emergency medical care immediately if you have:

• Hives
• Seizures
• Cold sweats
• Bloody diarrhea
• Irregular or rapid heartbeat
• Difficulty breathing or swallowing
• Itching or swelling of the face or throat
• Numb, pale or blue-tinted extremities
• Changes to your speech or vision
• Severe stomach pain
• Heaviness, pressure or tightness in your chest, jaw or neck

Can You Reduce Your Out-of-Pocket Cost for Sumatriptan?

If you have Medicare, it may be possible to lower the cost of prescription medications, such as sumatriptan, through one of the following methods:

• Ordering a 90-day supply: Some Medicare plans let beneficiaries purchase a 90-day supply of the drug, which may reduce the total cost.
• Extra Help: Low-income seniors may qualify for the Part D Low-Income Subsidy program, commonly referred to as Extra Help. This federal program is designed to help low-income seniors cover the costs of prescription medications.
• Patient assistance programs: Many pharmaceutical companies offer subsidy programs for low-income seniors who couldn't otherwise afford to purchase essential medications. Seniors who meet a program’s income requirements may purchase medications directly from the manufacturer at reduced rates. However, these programs don’t typically cover generic versions of these drugs.

Medicare beneficiaries who want to explore additional ways to save on prescription medications should contact their local senior center, which may be able to connect them with Medicare counseling services, community assistance organizations and other helpful resources.