The Secrets of Insurance Coverage: Finally Get your Migraine Treatment Covered

Every day, there are discoveries in the medical field. Scientists are working hard to provide the migraine warriors with the treatments they need to cope with day-to-day life.

However, not every treatment is available for everyone, and some migraine patients may struggle to obtain coverage for the treatment they need. More often than not, getting insurance coverage can be a long process that involves trying a series of treatments before the patient finally gets the one that works just right.

Here, we will discuss the process of getting insurance coverage, how to work with a healthcare provider, the Botox treatment for chronic migraine, and the tips for getting better coverage for your migraine headaches.

Continue reading to find out all about the insurance coverage for migraines!

Getting Insurance For Migraine Treatments

In reality, patients rarely have to pay for the full cost of the migraine treatment. Most migraine patients in the US do have some sort of insurance – commercial or government-issued. Paying out-of-pocket for the complete treatment is extremely rare – as most people do have some assistance with paying via their insurance.

How do things work with using insurance to cover your migraine treatment? Usually, the insurance company will provide you with a list of medications and treatments on the formulary. The insurance formulary is the official list of prescription drugs covered by the insurer.

The medications on the formulary are either completely or partially covered by the insurance – so chances are, you might not even have to pay anything. For the drugs or treatments that aren’t on the formulary, the patent must pay a larger portion of the cost – which is commonly the full cost of the drug.

Do keep in mind that for most treatments and medications, you will have the responsibility for a co-pay, but it usually depends on your health plan. Moreover, keep in mind that new medication for migraines will be very expensive, even if they are on the health insurance formulary.

Prior Authorization

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What every migraine warrior needs to keep in mind is that even when you do find a medication that could work for you, there are some steps you need to take first. Many health insurance companies require extra steps before they finally agree to cover the cost of your medication.

New treatments for chronic migraine like the anti-CGRP migraine medication or Botox (Onabotulinum Toxin A) are not easily accessible. Usually, the insurance provider requires the patient to take other chronic migraine medications or treatments first.

There has to be documented paperwork that you have tried other options for treatment and they failed to provide you with success. This process is also called prior authorization, and applying for medication or treatment starts this process automatically.

Moreover, some medication manufacturers may offer migraine patients the co-pay while the patient waits for prior authorization with insurance. This healthcare program is called a bridge.

To get in touch with a manufacturer that offers a bridge program, you will have to talk to the pharmaceutical company directly. The company will ask you about your medical history, your issues, other medical conditions you may have, and so on.

Do note that though this seems like a great way to access drugs or treatment for your migraine sooner, it also comes with certain risks – and we are not talking about the side effects. For example, the insurance companies could still refuse the prior authorization or charge a co-pay that is too expensive for you. Also, patients that rely on government insurance like Medicaid or Medicare are not eligible for bridge programs.

Appeals

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If you get your drugs covered by your insurance plan immediately – that is just great. However, that is not always the case. Even if the doctor prescribes it for you, you may still be denied coverage.

If that happens, you and your doctor can appeal the decision. Do note that the process of appeal can take a few weeks or even months – and you could still be denied coverage for migraines after numerous appeals.

Why do some people get denied coverage by their insurance company?

Well, often the reason why people get denied is that they didn’t meet the criteria required by the insurance company or they didn’t try the medicine in the same drug class that is already on the formulary.

Sometimes getting approved for coverage of your medication can be a very frustrating process. If you get denied again, talk to your doctor about the next step that works best for you.

New Treatment – Botox For Chronic Migraine Patients

In 2010, the FDA approved using Botox for migraine relief. It’s used for treating chronic migraine headaches and to improve the quality of life. Patients reported having fewer days with headaches each month after undergoing botox injections for migraines, a study shows.

Almost every insurance plan covers the treatment for chronic migraine relief – even Medicare and Medicaid. The patient will have to cover the costs of the co-pay, but that’s a small fraction of it.

However, keep in mind that most health insurance companies approve the use of Botox treatment only after the patient has undergone at least two other migraine preventatives before they approve the Botox injections for migraine prevention.

Most insurance companies require prior authorization for getting approved. If you do not wish to undergo the whole prior authorization process, you will probably have to cover the services costs out of pocket.

Work with your insurance provider and your healthcare provider to make sure that you file all the medical history documents correctly. Be patient with your insurer as the prior authorization process can take several weeks or even a few months.

Because of that, many migraine warriors join a Botox Savings program to save up for chronic headache treatment. The Botox Savings program can supplement the insurance payment and help you pay off the treatment faster.

Ask your healthcare professional about the botulinum toxin product, and whether they can ensure access for you.

Tips For Getting Better Insurance Coverage

1. Get A Recent Copy Of Your Insurance Company’s Formulary

Many migraine patients depend on a prescription to treat their attack – and because of that, you should always have a copy of your insurance’s formulary. The doctor and the pharmacist you’re seeing can inform you what medications are on your health insurance – but you should always be your own advocate.

For most insurance companies, you can find the formulary on the website, but if you are unable, they can send it upon request via email. Print it out, and take it to your doctor, so you can discuss prescriptions covered by the health insurance and what you need from their practice to get approved for coverage.

2. Compare Policy Coverage For Each Treatment

Every year before you renew the health insurance, you should take your time to research the treatments you need to live with chronic migraine. Then, look up the coverage for treatments you would like to try to ease your symptoms and start shopping.

Take your time to research whether your treatments are on the formulary for the insurer you’re considering. This is a huge decision factor, so don’t rush to sign with a company that may not be able to provide you with the treatments you need.

3. Connect With Someone At Your Chosen Insurance Company

To get more coverage for your migraine treatment, you will need to connect with someone at the insurance company who can understand what you’re going through. Hopefully, that won’t be too hard to find.

Over 14% of adults in the US are affected by a migraine. So, the chances are, you might be able to get an insurance rep or a supervisor that knows exactly what you’re dealing with. Talk to someone who can empathize and who can provide you with a human response that you need.

Do remember to get the insurance rep’s name so you can trace back to them in case the pharmacy doesn’t cover your claim for the prescriptions. Also, ask the rep to send you an email to confirm what you heard, so you have a confirmation in writing.

4. Involve The Doctor’s Nurse As Your Advocate

The first thing to getting the nurse to be the advocate is making sure that you saw your doctor recently or that you’ve at least made an appointment. You want your doctor to know what treatments you have tried, what works for you, and what doesn’t.

The nurse should be up to date with that information, as well. The doctor, as well as the nurse, should be your advocates with the health insurance company and the pharmacy benefits manager. They are the gateway to getting your Migraine insurance covered.

You should be familiar with the nurse working at your doctor’s so you can reach them if you ever have a problem with your migraine prescriptions. Also, remember that you should find a doctor or practice that specializes in headache treatments.

A neurologist will likely be more effective in making an appeal to your insurance company, rather than a GP.

5. Appeal With Research, Your History, And Data

Healthcare reforms involve new policies, which further make more work for every health care provider. Nurses, pharmacists, insurance representatives, doctors, and health care providers are all human – and they can struggle with the new policies just like everyone else.

Appeal to the insurance company with good data, from good medical sources. Also, you should keep all of your case history documented, such as with the Migraine Buddy app on your phone.

Insurance Coverage – Bottom line

To conclude, getting coverage for your treatments or medication for migraine headaches can be a frustrating process. We, migraine warriors, have to stick together and help each other.

Let’s be honest, over the counter medicines simply don’t offer enough migraine relief for everyone. Many of us rely on muscle relaxants because of neck pain and need insurance plans that cover more medication options.

Talk to your healthcare provider before switching any medication, and talk to them about getting access to Botox treatments. Join a savings program or consider doing prior authorization to get more permanent relief!

Jenny from Migraine Buddy
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