Most insurance companies don’t cover migraine treatment—here’s how you can advocate for yourself.
Migraine is often referred to as an “invisible disease.” Its symptoms are not always clear from an outside perspective, and sometimes, it can be difficult to diagnose. But for people with migraine, the symptoms are often debilitating and affect day-to-day life. When other people don’t recognize migraine for the very real disease it is, it can feel like yet another blow.
Unfortunately, because many people are unaware that migraine is a disabling neurological disease, insurance companies usually do not recognize migraine and therefore do not cover treatments for it. This makes migraine treatment very expensive. Both healthcare providers and people living with migraine need to work together and advocate for accessible, affordable treatment for migraine.
Why won’t my insurance cover my treatment?
How do insurance companies refuse to cover migraine treatment? There are several ways this can happen.
- “Fail First” or Step Therapy
In some cases, an insurance company will require a person to try their preferred treatment, such as a certain drug, before they can take what their doctor originally recommended and prescribed. The insurance company will often choose a less expensive drug or drugs as the “fail first” medication to control their costs.
This policy is called “fail first” therapy because a person first has to prove that the insurance company’s preferred treatment does not help their symptoms—even if it is clear the medication will not be as effective. It is also called “step therapy” because this process can require someone to take multiple steps or try more than one medication before finding the one that works for them.
- “Off-Label” Use
Since the development of migraine-specific treatment is relatively recent, a lot of the tools doctors use to effectively treat migraine were originally approved for treating other conditions. But if a treatment has not been approved specifically for migraine, using it to treat migraine is considered “off-label” use. Insurance companies may also consider certain treatments or medications “experimental” and will not cover them for this reason.
- Formulary Changes
The list of medications covered by your insurance plan is called the plan’s “formulary.” If your insurance company does not have your medication listed on the formulary, it is likely not covered. At certain points, typically once a year, the insurance company may make changes to this list. This can change the coverage of your prescribed medication and force you to switch to a different one that is covered.
This type of change is known as “non-medical switching.” Whether it’s switching a preventive treatment or an acute one or from one class of medication to another class, forcing you to change migraine meds could affect your migraine management or cause new side effects.
- Layered Therapies
Many people with migraine need a layered approach to treat and manage their symptoms. This approach may include preventive medication, acute medication and other therapies. Similarly, doctors may choose to use multiple medications at the same time to boost their effectiveness or better control a range of symptoms. For example, in some cases doctors have had success combining triptans with NSAIDs or by prescribing OnabotulinumtoxinA (Botox®) alongside anti-CGRP monoclonal antibodies. These dual therapies can sometimes offer relief when a person is not responding to a single medication or treatment alone.
However, covering multiple types of treatment will cost an insurance company more than covering just one type of treatment—so to reduce costs, your insurer may decide to only cover one treatment at a time.
How can I advocate for myself?
Drugs and treatments that are not covered by insurance can be very expensive. To get your migraine treatment covered by insurance, you will likely have to advocate for yourself. The goal is to convince your insurance company that the prescribed treatment is “reasonable” and “necessary.”
- Call and email your insurance company often.
Be persistent! You can find contact information on the back of your insurance card or on the company’s website. Take notes on what your insurance company says, including the date and time of your conversation, the name of the representative you spoke to and a confirmation number for the call.
Contact or request to talk to the “pharmacy benefit manager,” the actual person who oversees the benefits of the plans. Ask for the insurance company’s “medically necessary criteria” so you know what is needed to prove your treatment is medically necessary.
- Submit an appeal.
If your insurance company will not provide coverage, you should receive a determination letter stating the reason. You have the right to appeal. An appeal is a request for your insurer to review its decision to deny coverage. Be aware of deadlines for an appeal and make sure you submit your appeal in that timeframe.
- Get your doctor’s office involved.
Your doctor’s office deals with insurance companies every day, so they can help you. The staff can make sure you have a signed letter from your doctor that explains why the prescribed treatment is medically necessary. They may be able to submit the appeal for you or help you write a letter of appeal.
- Provide support information.
Your doctor may also be able to share medical articles or specific state or federal laws that back up your case. For example, this type of information can show that a medication is FDA-approved for at least one other condition or that a drug is accepted within peer-reviewed medical articles. In some states, that means an insurance company cannot deny coverage for an “off-label” use.
- Don’t give up.
There can be multiple steps in an appeal process, so don’t give up. Resubmitting an appeal will typically move it to someone higher up in the organization. If the insurance company still refuses to cover your treatment after multiple levels of internal review, you can also appeal to an independent third-party organization for an external review.
How do I navigate my insurance company and migraine?
When seeking treatment for migraine, there are a few challenges you may encounter. It’s helpful to know about them upfront so you can quickly head off any issues.
Some insurance companies require prior authorization. Prior authorization means you or your doctor need to contact the insurance company for approval before the treatment will be covered. It’s typically required when your prescribed medication, dosage and/or quantity is different from your insurance plan’s standard coverage.
Prior authorization can slow down your treatment process and delay care. Be sure to discuss with your doctor and insurer to get any necessary prior authorizations completed as soon as possible.
You’ll also want to stay alert to the cost of your co-pays. A co-pay is the fixed fee you pay for different covered healthcare services, like when you visit the doctor or fill a prescription. This amount may vary depending on whether you’ve met your deductible. For some migraine treatments, an insurance company will cover the treatment but charge a high co-pay.
If you notice this happening, contact your insurer to get more information. If needed, dispute the amount. You can also check if the drug manufacturer offers a co-pay assistance card. These are often found on their website. You can also talk to your pharmacist about other ways to reduce your prescription costs.
The American Migraine Foundation has many resources with tips on advocating for yourself. Reference this information for support in navigating the insurance process. While insurance-related challenges can be frustrating, stay hopeful. Migraine is not “just a headache,” and you deserve to receive effective treatment.
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.
