Many people think that they have to take the medications their insurance requires rather than those their doctor prescribes. This is not true, although sometimes we do have to follow certain steps in order to get approval. Read this blog and follow the tips below to help get your migraine medications covered by your insurance and to appeal any denials.
Most of us with migraine have been there. Our doctor or other medical care provider prescribes a new medication to help manage our migraine attacks. We get excited to try a new medication that may help ease our symptoms, only to be let down by the insurance company when they refuse to cover the medication. Rather than allowing you to use a medication prescribed by your medical team, the insurance company wants you to try one they recommend first. This could be due to something called ‘step therapy, because a medication is not on the company’s formulary, or even because your insurance company doesn’t understand why you may need a combination of therapies. All of these scenarios happen often, especially as new and more expensive medications become available.
Do I have to follow my insurance company’s medication recommendations?
Dealing with insurance companies can be challenging. There are lots of hoops they want us to jump through. However, if you work closely with your medical team and your insurance company, you can often get your new prescription covered. Insurance companies should not dictate which medications are best, only your medical team can do that. Here are a few steps you can take to help get your migraine medications approved:
Step 1. Check the insurance company’s formulary.
Each insurance company has its own list of preferred medications, known as a formulary. Formularies are listed on the insurance company’s website, or you can call the phone number on your insurance card and ask which medications are covered. First-tier medications will be the least expensive, while third-tier will be the most expensive. If the medication prescribed is not new on the market, ask if there is a generic version or see if a similar one is available under a different brand name. One brand name may be second-tier, another may be third-tier, and yet another may not be covered at all. Once you know what the formulary will cover, talk with your doctor to see if changing the brand name is okay. Of course, if you are trying a new migraine medication then that will not be possible since only the brand name will be available. In this case, it will not yet be on the company’s formulary so your doctor will need to file information to appeal any denial and show medical necessity.
Step 2. Get prior authorization.
Ask your doctor to be ready to submit a prior authorization (PA) when the medication is prescribed. Once your pharmacy has let you and/or the doctor know that a prior authorization is needed, your doctor can communicate to the insurance company why it should be covered. This authorization will explain why this medication is an important part of your treatment plan and will show that you have already met their criteria for any required step therapy. If you are allergic to or cannot take certain medications due to other chronic conditions, this information should also be included in the prior authorization request and will show your insurance company that you cannot take the medications they prefer first.
Your doctor’s office should have processes in place for prior authorization, however some offices are not quick to process these, so it is important for you to follow up with them and your insurance company regularly. After your doctor submits the prior authorization you may receive a variety of responses. It may be immediately approved. The insurance company may have a medication they prefer in the same category based on their formulary. The reason for denial could be an administrative or medical coding error. It is also possible that your doctor’s office doesn’t follow up with questions from the insurance company quickly enough and so the case is automatically denied. Again, this is where YOUR involvement helps in tracking the whole process and making sure things are moving along as needed. Many times you can call the insurance company directly to ensure that a PA has been submitted and then to ask the status of it.
Step 3. Follow-up with the insurance company.
If the insurance company denies the prior authorization, your doctor can ask to speak to them directly. This is called peer-to-peer authorization. The doctor can explain in more detail why the prescribed medication is recommended. If the insurance company still turns down the request to cover your medication, it is important to know what the reason for denial is. Many times it is due to a request for step therapy. The decision for which medications are appropriate should always be a decision made between you and your doctor, although in some situations, it is possible to find a medication that works for you during the step therapy process. This would obviously be a fantastic outcome! Sadly, however, for some the step therapy process does not help, and it may even make your migraine symptoms worse. If you have to go through step therapy, make sure to keep track of your symptoms and share them with your doctor throughout the process.
In addition to your doctor calling your insurance, many times patients can also call themselves to file an appeal of a denial and to find out the reason for denial. This is also a great way to make sure that your doctor’s office has submitted the necessary paperwork. Remember, the squeaky wheel gets the oil, so don’t be afraid to advocate for yourself!
Share your experience with insurance denials
Has your insurance company required you to try medications they prefer (step therapy)? Have they tried to override your doctor’s medical advice? What has been your experience with appealing medication denials?