Although in an ideal world medical insurance companies would exist purely to make sure you can get all the meds you need at a price you can afford, it doesn’t always work that way. Most insurance companies are businesses. They flourish because they’re able to make a profit. Even the ones that run on a no-profit basis have to control expenses. This sometimes means certain drugs are not covered, or that cheaper alternatives are covered instead of the more expensive options.
It can sometimes create problems for migraineurs who depend on insurance coverage for their medications. Here is a rundown on some of the problems you might encounter, and some possible solutions or courses of action to try.
Prescriptions Not Covered As Written
Not all patients are the same, having different medication needs, but some insurance companies have a one-size-fits-all policy. This means you may sometimes run into the problem of presenting your prescription at the pharmacy only to be told that your insurance doesn’t cover the prescription the way your doctor has written it.
The problem typically occurs because your insurance may only cover an average dose needed over the period of one month. If your needs are higher, your insurance may fall short.
This doesn’t mean you should automatically accept that you cannot get your prescribed dose covered by your insurance. The solution may be to ask your doctor for a ‘Prior Authorization’.
Prior Authorization is simply a process whereby your doctor asks your insurance company to cover your medication needs as prescribed. This happens when it’s necessary for your health that you receive medication in a quantity and dosage that differs from the insurance company’s standard cover.
It’s a process all doctors and pharmacies are familiar with, but it may not be offered automatically if you don’t raise the issue yourself. If you experience this type of difficulty in getting your medication as your doctor advises, ask how to get a Prior Authorization so you can start the process to resolve the issue.
Another possible solution is to ask your doctor if you can get samples to cover your medication shortfall. Prescription samples are often held in doctor’s offices, although it may be more likely that a neurologist would have samples that could help. Asking is key to success in these cases. The very worst that can happen is you’ll be told it’s not possible, but you will have at least tried.
Step Therapy and How it Works
Step therapy is another form of prior authorization. Migraineurs trying to get Botox treatment for their migraines, for instance, will run into a step therapy process. It works like this:
Before you can access to more expensive or more recent forms of a drug or therapy, you must first have tried a less expensive form of treatment. Insurance companies have their own formularies (this is a list of the drugs they cover) that have proven most effective for migraine sufferers. Top of the list are the drugs that cost the least.
Only after all forms of conventional drug treatments (starting with the most generic and working up to more specialized drugs) have failed, will you be authorized for treatment such as Botox under your insurance plan.
How to Maximize Your Influence
You can strengthen your personal case for getting insurance cover for your needed migraine medications by adopting some or all of the following:
- Keep your migraine diary up to date — This contains all your evidence for what helps and what doesn’t. It shows the drugs you’ve tried, when you tried them, how long you were on them and all the other factors surrounding your migraine, including missed work and reduced quality of life.
- Make Your Doctor Your Advocate — Your doctor and his or her nurse are your best friends when it comes to negotiating for the drugs you need. Larger practices have more influence, and specialist clinics may have an even stronger voice.
- Compare Insurance Policies — Check the formulary before you sign on the dotted line. Many insurance companies post their lists online, or will mail them out upon request. It’s a good idea to have these to hand when you visit your doctor so you can discuss your needs and how they can best help you get the medication you need.
- Advocate for Yourself — You are your own best expert, and it’s important not to give up. If you get a refusal, appeal, even if you expect a denial.
You could also consider joining a migraine community of fellow sufferers for support and advice, where you may learn about migraine friendly insurance companies or find out better ways to engage health care professionals on your behalf.