First Name:   Last Name:

Email Address:    State:

Your Insurance Company:

Type of Coverage (HMO, PPO, etc.):

Is your insurance through your employer? Yes No

Which triptan(s) have they limited? Please select one or more Imitrex, Tablets Imitrex, Nasal Spray Imitrex, Injections Amerge Zomig, Regular Tablets Zomig-ZMT, Dissolvable Tablets Maxalt, Regular Tablets Maxalt, Dissolvable Tablets Axert Frova
    To select more than one, hold down your Control key while selecting.

What are the limits?

Have you contacted the insurance company on this issue? Yes No

If so, what was their response?

Contact Phone # for insurance:

What effects do the limits have on your care and health?
   

Other comments:

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