Navigating the insurance process can be daunting. Many of the older preventive and abortive treatments are easily available with health insurance in the USA, although some have high co-pays and are approved in limited monthly quantities. However, frequently there are access barriers put up by insurance companies. These can be challenging and time-consuming to resolve, and this is especially true for the newer migraine medications, combination therapy, and medical devices.
Prior Approval (PA)
Some of the treatment options require either a “Prior Approval” from your doctor in order for insurance to cover it. These are often treatments that are on your insurance company’s formulary but not accessible without a PA request from your doctor, which normally requires them to submit additional information.
Step Therapy
Some insurance companies will require that you go through “Step Therapy” before they approve medications prescribed by your doctor. This is where you have to try and fail, specific other treatments first, often multiple medications. Sometimes this is required in combination with a PA.
Formulary Exception
There are some medications that require a “Formulary Exception” request to be completed by your doctor. This is normally needed when the treatment is not listed on your insurance company’s formulary list. Your doctor has to submit additional information to show medical necessity, explaining why treatments on the formulary are not appropriate.
Not Covered
Some medications and many of the devices are not covered by insurance at all. At times it is possible to appeal this with a medical necessity letter from your doctor and a long history of failed alternative treatments. The companies which offer medical devices for migraine are currently working on insurance coverage for patients.
Advocating for yourself is crucial in navigating this insurance process, otherwise treatment approvals can take longer than necessary or even simply not happen. It helps to stay on top of the status of any treatment your doctor has prescribed for you. Here are some options for self-advocacy:
- Call your pharmacy to make sure that they have communicated any denial to your doctor's office
- Stay in touch with your doctor's office regularly to get status updates
- Call your insurance company directly to initiate an appeal after a denial
- Ask other people with migraine for advice on how to navigate the process
- If all self-advocacy attempts fail, there are patient advocacy organizations such as the Patient Advocate Foundation which may be able to help
Download the Migraine Treatment Toolbox
Talk with your doctor to see if these options would be good to add to your treatment toolbox! Print out our Migraine Toolbox and bring it to your next appointment.