You’ve finally found a migraine treatment that works, but then you get the dreaded letter stating, “Your claim has been denied.” As if having migraine disease isn’t enough of a pain, being a professional patient often means fighting for the insurance coverage that you need to stay well.
Many of us are in a battle to get new migraine medications covered, and for good reason: Delays in treatment can allow episodic migraine to progress to chronic migraine. Here’s what you should know, along with tips for navigating our complex health insurance system; it’s tricky, but it’s still possible to get the treatments you need covered, even after denials.
Navigating the Insurance Maze: Common Roadblocks to Migraine Treatment
It’s frustrating but common for people with migraine to experience delays in getting their prescription medications, for both those with commercial health insurance and those who rely on Medicare Part D for drug coverage.
Here are some of the insurance hurdles people with migraine often face:
Nonmedical Switching
Changes in coverage can lead to nonmedical switching, where a patient is required to change from one prescribed medication to another for a nonmedical reason, such as the treatment they were on no longer being covered by insurance. For a person with migraine who has navigated the trial-and-error process to find a treatment that works without intolerable side effects, being forced to switch treatments is frustrating at best and often debilitating.
Prior Authorizations
Most insurance providers require prior authorizations, or an extra approval step, before certain treatments are covered. Mark Youssef, MD, a neurologist and certified headache specialist in Cincinnati and a medical reviewer for Migraine Again, says the prior authorization process is frustrating for both patients and providers.
“It is quite a bit of work completing a prior authorization; often, there are many questions, you have to search through the note(s) for the answer, and a single missing criterion can cause a rejection. Moreover, the requirements and lists of questions seem to get longer and more complicated over time,” says Dr. Youssef.
Step Therapy
Additionally, step therapy or "fail first" on a less expensive treatment, like amitriptyline or a triptan, is required before most insurance companies will approve coverage for newer, more expensive medications. For example, Botox injections for migraine treatment and anti-CGRP medications are often approved only after a patient has tried two or more older, cheaper treatments.
5 Tips to Deal With Insurance Coverage Hassles and Wage an Effective Appeal
1. Know Your Insurer’s Formulary
Every health insurer regards treatments differently and has a unique formulary that dictates which treatments are covered. To make things more complicated, these formularies may change from year to year, so you should check your current plan's formulary annually.
If you’re like most people with migraine who depend on a prescription medication to treat their attacks, this is imperative. While your doctor’s office and pharmacy can tell you which migraine medications are on your insurer’s formulary, you are your own best advocate.
Many insurers post formularies on their websites and/or will mail you a copy upon request. Get these annually before January 1 to avoid a surprise at your pharmacy counter. You can also take it to your next doctor’s appointment to discuss what’s covered and what assistance you’ll need from their practice to get it covered.
2. Compare Policy Coverage of Your Desired Migraine Treatment
If you have the ability to choose between health insurance plans, examine the treatments you rely upon or would really like to try for migraine relief before you renew your health insurance. Then start shopping.
It’s best to know ahead of time if the CGRP-blocking preventive medication that’s helping you isn’t on the formulary for one of the insurance companies you have or are considering.
Another thing to consider: Sometimes a health savings account (HSA) can offer more flexibility with trying things like supplements and devices, which are not usually covered by health insurance.
3. Engage Your Doctor’s Office as Your Advocate
First, be sure you’ve seen your doctor recently or get an appointment to do so. You want your healthcare provider and, perhaps more important, their nurse or assistant, to know what you’ve tried, what works, and what doesn’t. This person is your advocate with your insurance company and the pharmacy benefits manager (e.g., Express Scripts) that processes your migraine insurance coverage claims.
You’ll want to make sure you can reach this person in the event of an issue with your migraine medications. And it goes without saying that a headache specialist’s practice is likely to be far more effective at making an appeal than a general physician's office. While several types of doctors can treat migraine, headache specialists have more training and experience with migraine and other headache disorders; if you’re not getting relief with your physician, it might be time to consider a change.
Youssef shares, “A large group is going to have more resources and more staff to spread out work and have individualized staff whose job might be to work on prior authorizations all day. In a small office, a physician might have a medical assistant who is doing a bit of everything.”
4. Appeal Insurance Denials With Data, Evidence-Based Research, and Your Personal History
If you receive an insurance denial, arm yourself with knowledge and data for the appeal process. First, find out why your claim was denied. Is step therapy required? Is a layered treatment approach with multiple preventives considered too expensive? Are they refusing to cover a CGRP-blocking acute medication at the same time as a CGRP-blocking preventive?
Your doctor’s office may have staff who help with appeals, but you’ll likely need to request a letter of medical necessity regardless. You’ll then want to write a letter explaining that you are appealing your insurer’s decision before the appeal deadline (which should be stated in the denial letter). Include your physician’s letter of medical necessity, along with any other evidence-based information that could help.
Records are also an excellent tool for migraine insurance coverage appeals. Consider documenting your personal case history using one of the useful migraine and headache tracking apps available.
If you’re looking for a case manager who can offer one-on-one help, the Patient Advocate Foundation is an assistance program that provides case management services and financial assistance programs to U.S. residents with chronic, life-threatening, and debilitating illnesses. The Coalition for Headache and Migraine Patients (CHAMP) Financial Assistance Guides are also great resources.
If your appeal is denied, you have the right to appeal to an independent third-party organization for an external review.
5. Don’t Give Up
Persistence and follow-up are key when it comes to overcoming barriers to getting your treatments covered. Many treatments are approved only after appealing, and insurers count on patients walking away after the first “no.”
If you keep pushing — by working with your doctor, submitting an appeal with strong medical documentation, and asking for an external review if needed — you increase your chances of getting the treatment you need covered. Every step forward is progress, and your health is worth the fight.
RELATED: ‘Advocate for Yourself; You Are Stronger Than You Think’
Final Thoughts
Going to the pharmacy only to learn your migraine treatment is stuck in the prior authorization process, or receiving a denial letter for a migraine treatment you need to function is beyond frustrating. Know you’re not alone, expect complications, and be grateful for those who are doing their jobs to help you.
It's an imperfect system, but a vigilant patient can sometimes win over a cost-cutting insurer with an informed appeal. Do not give up!