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I don't know that anyone can explain how it works or why the insurance companies can over-ride the physicians. It is one of the biggest - if not the biggest - problem with healthcare in this country. Some medications require prior authorization, so I would have your physician call to see if that is the case. And if it's not, then I would have your physician do an appeal.

@farawayviolet: I had this same problem!

In a nut shell, they aren't overriding your doctor, per se, the pharmacy will still give it to you - you just have to pay like $150. They are just saying they won't pay for more than 12 pills because obviously some dude is up there proclaiming morning sickness only occurs sporadically or something ridiculous like that. Zofran is not considered by insurance companies as "round-the-clock needed" (don't get me started on this) unless you are diagnosed with hyperemisis gravidarum. What you will have to do is call the insurance company and request the form that allows you to get medicine over the quantity limits. Your doctor then fills it out and requests that you are able to fill 60 pills every 30 days (assuming you have the extended release kind - i.e. the kind that dissolves on your tongue). I had already been told I had HG so this part wasn't an issue for me, but my specific insurance company (BCBS) doesn't approve it unless you are diagnosed with HG. In other words, you will want to mention to your doctor that your insurance companies requires them to provide a diagnosis or they will just reject the approval request. The approval process is usually fast tracked and you should get a letter from your insurance company pretty quickly that you can take to your pharmacy.

In the mean time, I would recommend taking Zofran as late as you can make it in the morning (assuming you have the 12 hour pill) and and going to be early. That's what I did until I got my approval. I know it stinks, though.

I hope this helps. I'm sorry if it isn't completely five year old level!

i would call your insurance first (member number on the card) they might tell you your plan prefers a certain generic or it might be easier to get the script through the mail order pharmacy. then i would call your dr and see what they recommend.... 12 seems like an odd number since i would think 30 would be once a day

I agree with what everyone else has said and had one additional thought: Zoloft (or its generic version whose name I can't remember) is a drug that has been on the market for a very long time– so I would ask your pharmacist how much it would cost to pay out of pocket. It isn’t fair (and it seems counter-intuitive) but I’ve run into situations where it’s cheaper to pay out of pocket for drugs than to pay the co-pay amount.

I took Zofran throughout my pregnancy, multiple times a day and my insurance company never had any issue whatsoever with me filling multiple Zofran Rx in a month (I took 60 pills + a month on average, sometimes 4-5 pills a day)

Wait...they would only cover 12 generic pills a month?

This generally only occurs with medications that are not taken on a daily basis - think migraine medicine, Viagra-type drugs, some sleep aids (Ambien). This is meant to prevent abuse and long term use since they're typically not taken on a daily basis. Like others said, I'd give your insurance company a call to figure out how to get them to cover more per month.