Getting insurance coverage for migraine treatments can be a confusing process. Watch this webinar to learn how to overcome common issues to get your insurance to cover treatments.
To navigate insurance and receive the migraine care you need, you’ll need to work closely with your doctor, pharmacy and insurance company. Our recent webinar brought together a panel of experts familiar with the common issues people face when trying to get their migraine treatments covered by insurance.
The webinar was hosted by Dr. Roderick Spears, a professor of neurology at Brown University. Panelists Dr. Carrie Dougherty, a neurologist and headache specialist at MedStar Georgetown University Hospital, Dr. Amy Gelfand, a pediatric headache specialist at the University of California San Francisco, and Angie Rutherford, a patient advocate who has had migraine her entire life, shared their experiences, practical tips and helpful advice on insurance for migraine.
Below, we recap what our panelists said about the process of getting insurance to cover migraine care, and their advice for how to address common obstacles along the way.
What is prior authorization and when do you need it for migraine care?
Imagine this: You’ve met with a doctor and formed a plan to manage your migraine, which includes a new medication. After the doctor orders your prescription, you receive a message from the pharmacy saying, “We contacted your health provider for verification.” You find out the prescription is “on hold.” What’s going on?
On top of medical insurance, people may have prescription drug coverage managed by a pharmacy benefit manager (PBM). The PBM creates a list of preferred medications called a formulary. If your medication is not included on this list, you will likely have to take extra steps to get coverage. One of these steps is prior authorization.
Prior authorization, sometimes called preauthorization, is when your doctor must submit a request to your PBM or insurance company explaining why certain medications or services are necessary. Even if your doctor prescribes medication, your insurance may need prior authorization before the pharmacy fills it. While prior authorization for medication can be denied for a number of reasons, there are a few common situations:
- You’re not using the medication for the FDA-approved purpose or condition.
- You didn’t previously try the required alternative treatments.
- You plan to use the medication in combination with other treatments that are not allowed.
- The medication isn’t included on the list of formulary drugs and is simply not covered.
Dr. Dougherty says the easiest route may be for the patient to reach out to the doctor’s office to let them know the pharmacy is requiring prior authorization. Your doctor will then provide the necessary information to the insurance company. In some cases they may need to explain why you cannot take other medications on the formulary list, whether due to severe side effects or other conditions that would make these drugs unsafe.
While it can be frustrating in the moment—especially if you’re waiting on a prescription—working with your doctor is an important part of the insurance process. “We’re all on the same team,” says Dr. Gelfand. “We’re all trying to work through it with you. And I think the more involved that you [as a patient] can be, the more likely things are to be successful.”
Challenges Getting Children’s Migraine Treatments Covered by Insurance
There is currently only one migraine preventive treatment and four triptans that are FDA-labeled for 12- to 17-year olds. To date, there are no migraine medications labeled for children under 12.
“If you’re under 18, a number of medications are going to be considered off-label, meaning that they have not yet been given [approval] for migraine in people who are under 18,” says Dr. Gelfand. “So very often insurance companies will deny coverage for patients in our pediatric headache program.”
Another challenge is that insurance companies sometimes do not recognize previous treatments that children with migraine have tried and found to be ineffective, such as cognitive behavioral therapy, certain devices or supplements.
What if your prior authorization is denied?
If your prior authorization is denied, don’t worry—you still have options. First, your doctor may prescribe a generic option. Unfortunately, generic alternatives are not always available for medications, especially newer ones.
In some cases, a medication may only be approved for a certain number of doses over a set period of time—meaning your prior authorization can be denied if your doctor is prescribing outside of these limits. Dr. Dougherty says in these cases, “oftentimes we get around quantity limits by using discount pharmacy programs like GoodRX and Mark Cuban Cost Plus Pharmacy.”
Alternatively, you may use a pharmaceutical co-pay savings program, which is a coupon to reduce your co-pay (the set fee you pay for a covered prescription). These programs are only available through commercial insurance and often have many restrictions, such as specific uses for medications, a limited timeframe during which the savings apply or being limited to a certain number of refills.
Many pharmaceutical companies also offer financial assistance programs for those who qualify based on income. To receive financial assistance, you will need to fill out an application that includes details about your income and treatment plan, and you may also need a signature from your doctor.
How to Appeal a Prior-Authorization Denial
As the patient, you are allowed to file an appeal when your prior authorization for a treatment is denied. You will need to provide documentation showing how you meet the coverage criteria. “Sometimes it’s just a matter of telling [the insurance company] that they didn’t read all the documentation—this happens a lot,” says Dr. Dougherty. “Sometimes I think they’re just waiting to see, ‘how hard do you want to work for this?’”
If you do not meet the established coverage criteria, you’ll have to explain why the medication should be covered. You’ll also need to submit supporting evidence, which may include notes from your doctor visit, journal articles about certain treatments or a letter of medical necessity from your doctor.
“Appeals require a lot of patience. They can take time,” says Dr. Gelfand. “Here in California, sometimes they’ll take 14 to 30 business days.”
If your appeal doesn’t overturn the denial, your doctor may be able to schedule a conversation with an insurance company doctor to explain why you should have access to the treatment they prescribed. Beyond that, you may also choose to take the insurance company to the state insurance board and challenge the denial—however, this can be a lengthy process.
Tips to Help Advocate for Yourself
For Angie, who has experienced migraine for her whole life, advocacy made a difference in receiving the treatments that actually work for her. Below are some tips on how to advocate for yourself when trying to navigate insurance coverage while living with migraine.
Plan for Coverage Pre-Authorizations
Angie had success with a specific calcitonin gene-related peptide (CGRP) medication. After using a pharmaceutical coupon that completely covered the cost for several months, that coverage suddenly changed at the end of a calendar year.
“It came time for prior authorization, and unfortunately the migraine medication that I was taking was not on the formulary,” says Angie. “But the other two CGRP [medications] were, and one I can’t take because it [conflicts with other medications] for me. So I tried the other CGRP. Unfortunately after six months, it was deemed a failure. My migraine symptoms had come back.”
Thankfully, after an appeal the insurance company decided to grant coverage so Angie could go back to taking the medication that works for her. However, she’s had to continually stay on top of the prior authorization process. “One thing that I have started doing is putting on my work calendar when my prior authorization is going to expire. It’s on my calendar to contact my doctor’s office 30 days before that expiration happens,” she says.
Know Your Medical History and Be Ready to Provide Details to Your Doctor
In order to get the care you need, it’s important to equip yourself with knowledge about your diagnosis, your medications and your medical history.
“Sometimes you may think we’re really nitpicky in a visit asking you about the list of medications you’ve tried,” says Dr. Dougherty. “[But] sometimes the requirements for a prior authorization can be as specific as what year you tried a prior medication, how many milligrams [the dose was] and for how many months you tried it. If I don’t submit that, they will deny the medication.”
Get in Touch With Your Pharmacy Benefits Manager (PBM)
It’s helpful to get to know your PBM so you can understand what is included on your formulary list of approved drugs.
“The way a medication gets on formulary is that you demonstrate demand. By generating a prior authorization from a large population of patients that are all served by one PBM, you show the PBM [that there is demand for that treatment],” says Dr. Dougherty. “If you just use the pharmaceutical company’s discount coupon, the PBM never knows that anybody wants [the medication]. Generating the prior authorization generates demand, which improves coverage of all medications.” Demand for medication raises awareness to insurers and pharmaceutical companies about which diseases are important to patients, and this has a direct effect on insurance coverage and investment by pharma.
Be prepared to work directly with your insurance company, with or your employer’s HR department in the case of employer-sponsored insurance. Angie notes that she has also found it helpful to research your particular state and learn when, and under what circumstances, you can or cannot appeal a pre-authorization denial at the state level.
“Advocacy is really the message here,” says Dr. Gelfand. “When we come at it from multiple angles—when the clinician team is coming at it and the patient family team is coming at it—I think that is when we’re most likely to be successful.”
The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. For more of the latest news and information on migraine, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.