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Headache & Migraine Treatment Access Guide for Medicines & Devices

Resources for Overcoming Insurance Barriers

Many new medicines and devices have been approved over the past few years for the treatment of headache, migraine and cluster diseases. While these new therapies create more treatment options, they have also led to a rising trend of burdensome barriers put in place by insurance companies between patients and what is prescribed by their health care professionals.

The CHAMP community is closely monitoring how insurance companies are covering medicines and devices. We are advocating at the policy level for broad coverage. We believe patients should have access to appropriate treatments prescribed by their health care professionals.

The most difficult access barriers for those with headache diseases are occurring on the following treatments:

CGRP Inhibitor Therapies

  • Aimovig™
  • AJOVY™
  • Emgality™

Medical Devices

  • Cefaly®
  • gammaCore™
  • SpringTMS®

Other

  • Botox®

The CHAMP community has information, templates, guides and support to navigate an insurance system as complex as any headache disease. Click on the tabs below to learn about the different types of patient access issues and find helpful resources to use in fighting for your rights when denied a treatment by your insurance company.

You Are Not Alone

Living with a chronic and painful disease is challenging and can be isolating. Know that you are not alone. You are a vital part of a community that is strong and powerful. You deserve access to the treatments prescribed by your health care professional. The members of CHAMP are here to support you as you journey through the ever-changing insurance landscape.

Access Issues Explained

Insurance companies often hide behind unethical practices to deny patients access to treatments. Below, the most commonly used access issues (or barriers) are explained.

CHAMP Financial Assistance Guides (Aimovig, AJOVY, Emgality & gammaCore)

Many pharmaceutical companies and device manufacturers have financial assistance programs for patients that are designed to get new treatments into the hands of patients, while insurance companies make their coverage decisions. To help you navigate these programs, CHAMP has created Financial Assistance Guides that provide easy-to-understand information, whether you have a private or public insurance plan or are uninsured.

Savings programs are generally not available if your medical insurance is provided by state or federal programs like Medicare and Medicaid. This is because the Federal Government does not allow people who are enrolled in these insurance programs to benefit from bridge or co-pay assistance programs.  If you are struggling to get Medicare or Medicaid to cover your treatment, contact the manufacturer who will help determine eligibility for other financial assistance programs.

Prescription Coverage & Formularies

Every insurance company has a list of prescription medications that they will cover. This list is called a formulary. Within a formulary, medicines can be placed into tiers that determine how much of the cost the insurance company will cover and how much you will have to pay.

Formularies are typically reviewed by an insurance company once or twice a year. Even if a new drug is approved by the FDA, insurance may deny coverage until their formulary review. Leaving patients with long gaps of time before they can try a newly approved treatment. When a new medicine is added to an insurance company’s formulary, it could be placed in a tier that requires a high co-pay from the patient (this is called Adverse Tiering).

Patients can file a formulary exception. In addition, there are several prescription savings programs that help significantly reduce your out-of-pocket costs for prescriptions.

Prior Authorization

When your health care professional prescribes a treatment, test or procedure, many insurance companies require an extra step (or hurdle) of review. This is called prior authorization. Coverage can be denied if a patient and their doctor’s office don’t go through the prior authorization process or if the decision is negative.

Prior authorization creates access barriers because of the amount of red tape a patient has to go through to obtain approval, delaying medical treatment. If a prior authorization is not obtained before a test or procedure, the entire cost could solely become the patient’s responsibility to pay for those services. If a patient is faced with denials, the decision can be appealed, further delaying access to treatment. The process of appealing a denial can be taxing, causing some patients to forego the recommended treatments.

Step Therapy / Fail First

When a new treatment is prescribed by your health care professional, insurance companies may use a practice called step therapy or fail first. Essentially, they require you to try and fail one or more medications before they will approve your new prescription. Even if your new prescription is on your insurance company’s formulary, “fail first” can still be a barrier to access. Step therapy may be required in order to receive a prior authorization approval.

In some cases, insurance companies will accept physician attestation (letter from your health care professional) stating you have previously gone through the required steps. In other cases, you have to provide extensive documentation of the treatments you have tried, how long you used each medication, side effects and reasons why you stopped taking a treatment. In worst case scenarios, your insurance company could require you to take medications you have already used, found ineffective, or even had negative side effects from before they will approve a new treatment.

Non-Medical Switching

Another prescription based barrier is called non-medical switching. This occurs when your insurance company forces you to switch to another medicine in the same class. The medicines are not identical and the switch is being forced for the financial benefit of the insurance company, while ignoring the potential negative impact on you, the patient.

One-on-One Help

The Patient Advocate Foundation (PAF) Migraine Matters program offers FREE one-on-one patient navigation support and services for those living with headache, migraine and cluster diseases. PAF has extensive experience working with patients on access issues. Whether it’s a denial of a treatment or a medical bill that doesn’t make sense, PAF’s trained staff will work directly with you to understand the issue, help gather information and assist in filing an appeal or complaint.

Case Managers will:

  • Work with you prior to the expiration of financial assistance programs to ensure continued access to prescribed medications
  • Screen you for eligibility and assist with enrolling in prescription drug assistance programs
  • Negotiate costly medical bills related to your care

For a full list of services offered, visit the Migraine Matters site.

Complete and submit the Request for Assistance Online Application and a case manager will be back in touch with you within 48 hours.

Online Communities

The following CHAMP member online communities can offer a forum to communicate with others that have experienced and overcome similar access issues.

Template Appeal Letters

Navigating insurance approvals and appeals often requires submitting explanatory letters. Below are a number of templates that will make it easier for you to draft your letters and ensure that you include all the necessary information.

Patients’ Rights

It is imperative that you be proactive about your care and treatment plan. Whether you are newly diagnosed, starting a new medication or device, or nearing the expiration date of a financial assistance program - you have rights when it comes to insurance coverage.

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