You wait for months to see your headache specialist. The day of your appointment finally comes. Your doctor has some ideas for new treatments that might work for you and writes you a prescription. You leave feeling hopeful. Maybe, just maybe, this one will work! But your excitement is short-lived as you find out your insurance company has denied the treatment. You feel frustrated, angry, likely on the verge of a migraine attack. Hopelessness returns.
Sound familiar? With more migraine treatments available than ever before, people with migraine can feel hopeful that they may find an option that brings them relief. Unfortunately, this process is not always as simple as it may sound. Insurance companies frequently construct barriers to treatment. While many of the older preventive and abortive treatments are easily available with health insurance, some come with high co-pays and are approved only in limited monthly quantities. For new treatment, insurers frequently restrict access and make it extremely difficult for people to obtain the prescriptions they need and which their doctors have prescribed. Insurance barriers create great stress for already exhausted patients and put additional strain on busy doctors’ offices.
Navigating Insurance
The insurance process can be daunting. The issues that arise are often challenging and time-consuming to resolve. Understanding how insurance works can be helpful in managing expectations.
Man and woman looking at paperwork and computer
1. Prior Approval (PA)
Some of the treatment options require a “prior approval” from your doctor in order for insurance to cover them. 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. This process theoretically can be quick, but some doctors’ offices don’t submit the information in a timely manner, even “timing out” the request altogether and necessitating the whole process to start over.
2. Step Therapy
Some treatments will require that you go through “step therapy” before they are approved. This is where you have to try, and fail, specific other treatments first. Sometimes this is required in combination with a PA. This is where is is really important for your doctor to have “on record” in your medical files which treatments you have already tried, so that they can submit that information to insurance if requested.
3. 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.
4. Not Covered
Some of the 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.
5. Tier Exception
This is a request, often submitted by the patient, once the medication has been approved but where the copay is too high because of the “tier” the medication has been put in by the insurance company. This process can take longer and is often denied, but is worth trying if you can prove medical necessity and financial need based on the higher copay of the current “tier.”
What can you do?
If your insurance company denies your treatments, you and your doctor can appeal, but this can take hours, days, weeks or even months to resolve if no one is overseeing the process. Here are some steps you can take to navigate it and help bring about a faster outcome.
Claim denied sign
1. Anticipate challenges and be prepared
It may be helpful to check your formulary, which is available either on your insurer’s website or by calling them, before you go to a doctor’s appointment. This way, you can better anticipate potential issues that may arise and talk with your doctor about how this can best be handled.
2. Advocate for yourself
Treatment approvals can take much longer than necessary, or not happen at all. While tiresome, staying on top of the process can move things along. Check out our tips for advocating for your treatment options here. This is where patients are often able to call the insurance company themselves to see the status of approvals and denials, and can even submit an appeal themselves. In addition, you can follow up regularly with your doctor’s office to ensure that information needed by insurance is being submitted in a timely manner. While this can be exhausting, it is the squeaky wheel that generally gets the oil faster in this situation!
3. Know your rights
Some insurance policies may violate certain federal and state protection laws. Knowing your rights can help you better navigate the process. Read more here.
4. Tell your story
You never know how sharing your story may help you, or others. Join the Migraine Meanderings and Hope for Migraine social groups and connect with others for support.
Issues Beyond Treatment Options
In addition to barriers to medications and devices, insurance companies can also make it difficult for you to access quality healthcare providers. Some companies have limited in-network providers or require you to see general doctors or other specialists first. This can make it really difficult to get an appointment in an acceptable timeframe, and may make it even harder to find a doctor you feel comfortable with, who is knowledgeable in treating headache disorders, and who is willing to partner with you. If insurance issues, or lack of health insurance, is preventing you from getting the care and support you need, don’t be afraid to appeal to see a doctor “out of network.” You may also benefit from a virtual headache clinical service like Neura Health either for a second opinion, or as your primary headache specialist (note: use code MIGRAINEM15 to receive a discount at Neura Health).
doctor wearing white coat holding stethiscope