Insurance companies don’t always cover every type of migraine treatment. Here’s how you can advocate for yourself and get the most possible coverage while managing migraine symptoms.
Migraine is often referred to as an “invisible disease.” Symptoms are not always clear from the outside, and sometimes it can be difficult to diagnose. However, for people living with migraine, the symptoms are often debilitating and affect day-to-day life. When other people don’t recognize migraine for the very real disease it is, it feels like yet another blow.
Unfortunately, because many people are unaware that migraine is a disabling neurological disease, insurance companies may not always recognize migraine and therefore do not cover some treatments. This makes migraine treatment very expensive for most people — but there are some things you can do to increase your chances of getting you and your doctor’s preferred treatment options covered.
Ultimately, both healthcare providers and people living with migraine need to work together to advocate for accessible, affordable treatment for migraine. Below are some tips on working with your doctor and insurance company to get your migraine treatments covered.
Why won’t my insurance cover my migraine treatment?
How do insurance companies refuse to cover migraine treatment? There are several ways this can happen:
“Fail First” Medication Policies
In some cases, an insurance company will require you to try a specific “preferred” treatment first — like a particular medication — before you can get coverage for the drug your doctor originally recommended and prescribed. This policy is called “fail first” therapy, because a person first has to prove that the insurance company’s preferred treatment does not help their symptoms — even if it is clear the medication will not be as effective.
The insurance company will often choose a less expensive drug as the “fail first” medication to control their costs. Additionally, many “fail first” medications are older and therefore less expensive drugs. Newer migraine treatments are often more effective and can have fewer significant side effects for some people. In these cases, insurance companies are asking doctors to try less expensive medications first in order to make sure the newer, more expensive medications are actually necessary.
Prior Authorization
Some insurance companies require prior authorization for certain treatments. Prior authorization means you or your doctor need to contact the insurance company for approval before the treatment will be covered. This is typically required when your prescribed medication, dosage and/or quantity is different from your insurance plan’s standard coverage.
Prior authorization can slow down your treatment process and delay care. Be sure to talk to your doctor and insurance company to get any necessary prior authorizations completed as soon as possible.
“Off-Label” Use
Since the development of migraine-specific treatment is still relatively recent, many of the tools and medications doctors use to effectively treat migraine were originally approved for treating other conditions. For example, sometimes blood pressure medications such as propranolol are used to treat migraine even though they were not originally intended for that purpose.
If a treatment has not been approved by the FDA specifically for migraine, prescribing it to treat migraine is considered “off-label” use and insurance will often deny these treatments for coverage. Insurance companies may also consider certain treatments or medications “experimental” and will not cover them for this reason.
Formulary Changes
The list of medications covered by your insurance plan is called the plan’s “formulary.” If your insurance company does not have your medication listed on the formulary, it is likely not covered.
At certain points, typically once a year, the insurance company may make changes to this list. In some cases, this may change the coverage status of your current medication and force you to switch to a different drug that is covered. This type of change is known as “non-medical switching.”
This may mean you have to change preventive treatments, or it could mean you have to switch from one class of acute medications to another. These changes are often frustrating since suddenly switching your medications may affect your migraine management plan or cause new side effects.
Layered Therapies
Many people with migraine need a layered approach to treat and manage their symptoms. This approach may include preventive medication, acute medication and other therapies. Similarly, doctors may choose to use multiple medications at the same time to boost their effectiveness or better control a range of symptoms. For example, in some cases doctors have had success combining triptans with NSAIDs or by prescribing OnabotulinumtoxinA (Botox®) alongside anti-CGRP based treatments. These dual therapies can sometimes offer relief when a person is not responding to a single medication or treatment alone.
However, covering multiple types of treatment will cost an insurance company more than covering just one type of treatment — so to reduce costs, your insurer may decide to only cover one treatment at a time.
How can I advocate for myself?
Treatments that are not covered by insurance are often very expensive. To get your migraine treatment covered by insurance, you will likely have to advocate for yourself. The goal is to convince your insurance company that the prescribed treatment is “reasonable” and “necessary.”
Follow the steps below to increase your chances of success with your insurance company.
1. Read coverage denial letters carefully.
You should receive a letter from your insurance company explaining why your prescribed treatment was denied. Read these letters carefully, as they will often include information you and your doctor can use to better advocate for future coverage. For example, they may outline specific treatments that need to be tried first.
Additionally, some information may have been overlooked. For example, your insurance company may note that you haven’t tried certain “fail first” medications or classes of medications when in fact you have tried and been failed by these treatments in the past. In these cases, you can provide supporting evidence that you have tried these treatments to appeal your denial of coverage for a new medication.
2. Call and email your insurance company often.
Be persistent! You can find contact information on the back of your insurance card or on the company’s website. Take notes on what your insurance company says, including the date and time of your conversation, the name of the representative you spoke to and a confirmation number for the call.
Contact or request to talk to the “pharmacy benefit manager,” the actual person who oversees the benefits of the plans. Ask for the insurance company’s “medically necessary criteria” so you know what is needed to prove your treatment is medically necessary.
3. Submit an appeal.
If your insurance company will not provide coverage, you should receive a determination letter stating the reason. You have the right to appeal. An appeal is a request for your insurer to review its decision to deny coverage. Be aware of deadlines for an appeal and make sure you submit your appeal in that timeframe.
In some cases, your doctor’s office may be able to help you with an appeal or sending other supporting documents to your insurance company. However, many offices do not have the time and resources to do this themselves, in which case it will be your responsibility. Make sure you talk to your doctor’s office so you understand what they can do — including things like submitting a prior authorization request — and what you will need to handle yourself.
4. Get your doctor’s office involved.
Your doctor’s office deals with insurance companies every day, so they can often help you understand why your coverage was denied. The staff can make sure you have a signed letter from your doctor that explains why the prescribed treatment is medically necessary. They may also be able to help you write a letter of appeal if you bring your denial of coverage letter and medical history with you.
5. Provide supporting information.
Your doctor may be able to share medical articles or specific state or federal laws that back up your case. For example, this type of information may show that a medication is FDA-approved for at least one other condition or that a drug is accepted for migraine treatment in peer-reviewed medical articles. In some states, that means an insurance company cannot deny coverage for an “off-label” use.
6. Don’t give up.
There may be multiple steps in an appeal process, so don’t give up. Resubmitting an appeal will typically move it to someone higher up in the organization. If the insurance company still refuses to cover your treatment after multiple levels of internal review, you can also appeal to an independent third-party organization for an external review.
How do I navigate my insurance company and migraine?
When seeking treatment for migraine, there are a few additional challenges you may encounter. It’s helpful to know about them upfront so you can quickly head off any issues.
Be aware of your co-pay amount before going to see your doctor or a headache specialist. A co-pay is the fixed fee you pay for different covered healthcare services, like when you visit the doctor or fill a prescription. This amount may vary depending on whether you’ve met your deductible for the year. For some migraine treatments, an insurance company will cover the treatment but charge a high co-pay.
If you notice this happening, contact your insurer to get more information. If needed, dispute the co-pay amount. For prescriptions, you can also check if the drug manufacturer offers a co-pay assistance card. These are often found on their website. You can also talk to your pharmacist about other ways to reduce your prescription costs.
The American Migraine Foundation has many resources on better advocating for yourself, including information on other common insurance questions. While insurance-related challenges are frustrating, stay hopeful. Migraine is not “just a headache,” and you deserve to receive effective treatment.
The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. For more of the latest news and information on migraine, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.
