Dr. Thomas Berk, assistant professor of neurology in the headache division at NYU Langone Health, talks medical insurance and prior authorization—and how healthcare providers can help
Medical professionals around the country are working every day to provide the right migraine treatment to patients who need it. Unfortunately, there are a few treatments that may not be as simple to obtain as others are—there can be a lengthy process involved and other drugs that need to be tried before a patient receives the treatment that works best for them.
In this article, we’ll walk through the process of accessing migraine medications in the U.S. and how to work with your healthcare provider—one of your biggest and best advocates.
Insurance vs. out-of-pocket
Most patients with migraine in the U.S. are going to have either commercial or government-based insurance. Rarely do patients with migraine pay for the full cost of their treatments out-of-pocket. If you do pay out-of-pocket, you will be responsible for paying the full cost of the treatment rather than receiving assistance through your insurance.
So, assuming you will be using insurance, how do things work? Typically, you will have a list of medications that are on a formulary, the list of approved treatments covered by your insurance provider. You will most likely be responsible for a copay, and the drugs on different tiers of the formulary may have different prices. In general, a new migraine medication is going to be expensive, even if it’s on a formulary—and many of them won’t be.
Prior CGRP Authorization
But even if the medication you need is covered by your insurance, there may be some steps that have to be taken before your insurance will agree to cover the cost of the medication. Many migraine medications, especially any kind of new treatment like injectable anti-CGRP migraine drugs or Onabotulinum A (Botox) need to be “stepped through,” meaning you have to have tried other medicines first. It needs to be documented that you tried other options and have not had enough success with those medicines or weren’t able to tolerate them. This process is known as prior authorization. Sometimes, just applying for a medication automatically starts this process.
Drug manufacturers may offer to cover the copay while the prior authorization is underway with commercial insurance. In order to access a bridge program, you have to contact the pharmaceutical company directly, and it will likely ask to review aspects of your medical record. While this may be a great option to access a medication more quickly, there is always the possibility that your insurance company will refuse the prior authorization or charge a copay that is higher than what you expected. Patients with government insurance, such as Medicare and Medicaid, are not eligible for bridge programs.
Denials and appeals
It may be that you get your medication very shortly after your doctor prescribes it, which is great. But sometimes, even after you’ve been given this migraine medication, you may be denied. If you are denied, you or your doctor may be able to appeal, although this may take several weeks (even months!) the ultimate decision is the insurance company’s.
But why would the insurance companies deny it? There are many reasons why you might be denied, including failing to meet the criteria they have laid out or that you have not tried a drug in the same drug class which is on their formulary. It may be very frustrating, both for you and your doctor. If you get denied, talk to your doctor about reasonable next options.
Providing care and support
Despite the number of hoops that need jumping through, the most important thing to realize is that healthcare providers are on the frontlines of this battle for you, the patient. Keeping a regular conversation with your doctor’s office and their support staff will help you better understand the process and the team approach it takes.