Health insurers use a number of ways to cut costs for migraine medications. This can mean your health plan will not cover the medication your health care professional prescribed or you will have to show that your migraines have gotten worse before your insurer will agree to pay for the treatment. Luckily, state or federal laws may protect you from these practices.
To find out whether your insurer may have improperly delayed or deniedaccess to your migraine treatment, ask yourself the following questions:
Step Therapy
Did my insurer make me try a different treatment before covering the migrainemedication that my health care professional prescribed?
This practice is called “step therapy” because it requires patients to try other treatments first and show they do not work. Your insurer may require you to try and fail on a lower-cost medication before covering the one prescribed by your health care professional, even if your migraines are very severe or last for many hours or days and keep you incapacitated, before covering the one prescribed by your health care professional.
Step therapy policies may violate certain federal and state laws if your insurer treats you and others with migraines differently because of your health condition.
Nonmedical switching
Is my insurer forcing me to take a different medication, even though my current migraine medication works well, by refusing to cover it any longer or increasing my co-pay?
This practice is referred to as “nonmedical switching.” It occurs when your insurer (not your health care professional or pharmacist) forces you to switch from your current migraine medication to a different (but not a generic equivalent) medication by either refusing to cover your drug any longer or increasing the out-of-pocket cost of your drug. For example, if you are on a preventive treatment, your insurer may force you to switch to an “acute” medication, which is used to stop a migraine after it has begun. The insurer might also force you to switch between different classes of preventative medication (such as from an anticonvulsant to a beta blocker). This could be especially troublesome if you have tried several medications over the years and finally found one that works for you. Non-medical switching can violate certain state consumer protection laws.
Prior authorization
Do I need to get my insurer’s approval before I can refill my migraine prescription?
This practice is called “prior authorization.” It happens when your insurer requires you or your health care professional to contact your insurer and get approval before the treatment is covered. Prior authorization policies can delay or interrupt care, waste time, and complicate medical decisions. For example, your insurer may require your health care professional to document that your migraines are accompanied by vomiting before your insurer will cover a nasal spray instead of a pill. Your health care professional may also have to show that you have had a certain number of migraines per month before your insurer will cover a preventative treatment. These policies can violate state and federal laws if applied in a certain manner.
Quantity Limits
Has my insurer limited the amount of migraine medication I can get at one time?
This restriction is called “quantity limits.” Often times, insurers will only approve a small quantity of migraine medications for short-term episodic treatment. These policies can create additional hassle, including more frequent and unnecessary visits to your health care professional or pharmacy. These policies may also violate state or federal law if applied in a discriminatory manner.
