Here’s a frustrating scenario that’s all too common. Your doctor prescribes a medication to treat your migraine, having judged it the best option for you. You head to the pharmacy to pick it up—only to be told it’s not covered by your health insurance. What gives?
The insurance industry tries to save money wherever it can, since its priority is its own bottom line, and not patients’ health. Sadly, the result is that many health conditions get shoddy coverage, including migraine. Migraine’s invisibility in society may be a factor in its being largely ignored by insurance: Without an uproar of patients demanding better coverage, insurance companies tend to reimburse very little in the realm of migraine.
Taking healthcare decisions out of the hands of doctors and putting them into the hands of bean-counters has serious repercussions for patients, including:
- Financial cost: Limited insurance coverage makes migraine an expensive condition to endure, especially for chronic patients.
- Time cost: Doctor-approved treatment plans can be needlessly delayed for precious weeks or months.
- Health cost: Insurance protocols may require patients to experiment with medicines other than those chosen by their doctor, further burdening their bodies and brains with chemical changes and side effects.
The experts’ advice for how to get the most out of an insurance system conditioned to say “no”: Be aware of their tactics, and be prepared to advocate for yourself.
4 Ways Insurance Says “No” To Meds
Between the physician’s pen and the pharmacy pickup, these are a few common ways insurance intervenes to save itself a few pennies.
“Fail first” therapy (also called “step therapy”): When insurance decides you must try other remedies first.
- Before your doctor can prescribe you a new-generation medication, insurance wants proof you’ve already exhausted older, cheaper options. Those older medicines may be an entirely different variety than what your doctor thinks is best for you. No matter. If you haven’t already tried your insurance’s approved first-line meds, try them you must.
- If after weeks or months you fail to improve on those meds, you’re ready for your insurance’s approved next-tier medication—which may or may not be the one your doctor originally wanted. If not, you must now allow that next medicine to run its course, to see whether it works.
- With each “failure,” you continue moving up the insurance tiers until you finally reach the medication your doctor ordered in the first place.
“Off-label use”: When insurance decides your medication isn’t meant for migraine.
- When medication is prescribed for something other than what it’s approved for, that’s called “off-label use.” One common example is when the anti-anxiety drug lorazepam is used to treat nausea in cancer patients.
- Few migraine-specific medications exist, especially for prevention.
- Research and experience has taught headache specialists that different headache variants respond well to medications approved for other things. For example, blood pressure medications, anticonvulsants, antidepressants and antipsychotics are typically prescribed as migraine treatments.
- Insurance companies sometimes object to such “off-label use,” saying that the medication’s approved use doesn’t match your diagnostic criteria for migraine.
Formulary changes: When insurance changes its list of covered medications — and decides yours is no longer on it.
- Your insurance company has a list of medications it is willing to cover, called a “formulary.” If your medicine is on the formulary, that medication is covered.
- When insurance changes its formulary, usually once a year but sometimes haphazardly, it does so without warning or explanation.
- If your insurance company has decided to stop covering your medication, it will shift you to a chemical cousin — a similar medicine. This is called “non-medical switching.” It means that the insurance company has made a medical change to your treatment plan, without your doctor’s authority.
Layered therapies: When the insurance company says you’ve had enough.
- Many migraine patients use more than one type of prevention medicines at the same time, especially for hard-to-treat chronic headaches that require more aggressive treatment plans.
- Insurance companies may be inclined to deny this layered approach to migraine therapy, deciding that one pricey treatment at a time is enough.
How to Advocate For Yourself
It’s hard to fight for yourself when you’re not feeling well. But when it comes to securing your own care, there’s no more compelling and passionate voice than your own. Use these tips to get the healthcare coverage you deserve:
Be persistent with your insurance company.
- Keep calling and emailing, and don’t lose momentum, even when you’re having the same conversation over and over again with different people. Your insurance company has no interest in keeping this conversation going, so it’s up to you to continue following through.
- Contact the insurance company’s “pharmacy benefit manager.” This is the actual person who oversees the benefits for your plan, and the contact person with whom your pharmacists and nurses discuss your coverage. Call the pharmacy benefit manager to directly advocate for the specific coverage you need. Their phone number is usually listed right on the back of your insurance card.
- Take notes, and keep them handy, so that when you follow up with your next call, you can pick up where you last left off.
- If you’re denied a medicine you were already on, be prepared to write and share your own account of how the medicine (or combined therapies) has increased your quality of life.
Enlist your doctor’s office in the fight.
- They wrestle with insurance companies daily, and want to see you get the treatment you need. They can help you by writing letters and making calls on your behalf, and gathering information and medical records.
- To help you, your doctor may need to know information that may not be readily available in your chart — for example, that zolmitriptan failed you in 2008, or that you tried topiramate 10 years ago and had side effects. Be prepared to answer such questions, or to provide a list of failed medications, so your doctor can re-document it in their advocacy for you.
Stay alert to high co-pays.
Every so often, you’ll get medicine-approval “victory,” only to get to the pharmacy and meet with an unwelcome financial surprise: a high co-pay for your medicine.
- If it’s a name-brand medicine, make sure you aren’t missing a co-pay card or other opportunity to lower the cost. Co-pay cards can now be downloaded from the manufacturer and often bring the cost down to between zero and 10 dollars per month for treatments.
- If it’s a generic medicine, believe it or not, occasionally they cost more without insurance than with it! Ask your pharmacist if your medicine would be cheaper to buy if you don’t use your insurance.
Keep the faith.
With every appeal you make to your insurance company, you’re fighting a battle in a larger campaign on behalf of everyone with migraine — and even more broadly, for patients everywhere fighting for coverage of their conditions. The health insurance industry’s business model is to deny and delay payouts so as to hold onto their money a little longer; it’s counting on wearing you down until you give up. But once you know their tricks, you just might be able to beat them at their own game. Persist!