Headache & Migraine Treatment Access Guide for Medicine & Devices
Many new medicines and devices are approved for the treatment of headache, migraine and cluster diseases. The new therapies create more migraine treatment options; however, they create a rising trend of burdensome barriers put in place by insurance companies.
The CHAMP community is 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 migraine treatment options:
- Ubrogepant (Ubrelvy)
- Rimegepant (Nurtec ODT)
- Lasmiditan (Reyvow)
CGRP mAbs (Calcitonin Gene-Related Peptide Monoclonal Antibodies)
- Erenumab (Aimovig)
- Framenazumab (Ajovy)
- Galcanezumab (Emgality)
- Eptinezumab (Vyepti)
- Allay lamp
- Nerivio Migra
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. CHAMP participants 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.
- Migraine.com – Medication Assistance Programs & Barriers to Treatment – Interview with Lindsay Videnieks from The Headache & Migraine Policy Forum
- Patient Advocate Foundation Webcast – Understanding and Navigating Your Migraine Treatment Access Issues
- CoverageRights.org – Insurance Barriers
CHAMP Financial Assistance Guides for FDA-Approved Medications
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.
- Migraine Again – 5 Tips to Deal with Insurance Hassles on Your Migraine Medications
- Migraine World Summit – 2019 Interview with CHAMP Executive Director on CGRP Access (subscription required)
- Patient Advocate Foundation Webcast – Understanding Your Medication Formulary
- Patient Advocate Foundation – Exploring Drug Tiers and Exceptions
- TEMPLATE: Patient Advocate Foundation – Filing a Formulary Exception
- GoodRx.com – Instant coupons for prescription drugs not covered by insurance – enter name of drug, dose, and zip code
- Migraine Research Foundation – Prescription Payment Assistance (scroll down to Prescription Payment Assistance section)
- U.S. Pain Foundation – Insurance And Finances (scroll down to the Insurance And Finances section and click on Financial Assistance)
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. Worst-case scenarios: Your insurance company could require you to take medications you have already used, found ineffective, or even had negative side effects before they will approve a new treatment.
- U.S. Pain Foundation – Step Therapy or Fail First
- Alliance for Patient Access Video – Understanding Step Therapy
- Migraine Again – The Battle with Insurance Companies for Costly Migraine Care
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.
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.
PAF also offers the Migraine CareLine – a dedicated phone line and online resource. Call directly at 1-866-688-3625 or visit https://migraine.
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.
- Patient Advocate Foundation – Sample Appeal Letter for Claim Denial – Use this letter as a template to appeal to your insurance company if you had treatment and it was subsequently denied
- Migraine.com – Preparing a Written Appeal Letter for Insurance Company (with Sample Appeal Letter)
- Headache & Migraine Policy Forum – Guide to Filing an Insurance Complaint for Migraine Patients and Providers
- Patient Advocate Foundation Webcast – Tips for Submitting an Insurance Appeal for Migraine Patients
- Aimed Alliance – State-Specific Insurance Appeal Information
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.
- CHAMP – Declaration of Rights for People with Headache Diseases
- Aimed Alliance – Migraine Patients Know Your Rights
- Patients Rising – What Every Migraine Patient Needs to Know
- Institute for Patient Access – Health Barriers and Migraine Are a Losing Combination
- Institute for Patient Access – Chronic Migraine, Chronic Insurer Denials