Migraine and headache sufferers go through a lot—piercing head pain, nausea, visual auras and the lifestyle upheaval that accompanies their condition. But if there’s one thing that rivals the sheer discomfort of a migraine or headache, it’s figuring out the insurance issues surrounding the condition’s care and treatment.
Understanding the most effective therapies, haggling over which costs are covered by insurance providers and putting a figure to the inevitable out-of-pocket expenses can all feel like a shell game, says Bray Patrick-Lake, a migraine sufferer and patient representative for the Food and Drug Administration (FDA).
“You see a migraine specialist, you pay for the appointment, you start the therapy and 30 days later you get a letter [from the insurance company] saying, ‘We won’t pay for this medication so you need to switch to this cheaper drug,’” Patrick-Lake says. “It’s very frustrating.”
That’s why it’s essential to get a handle on the process. Here are four recommendations gleaned from physicians, health insurance insiders and patient advocates to help remove potential roadblocks to care and put you in control of your life.
1. Love the Fine Print
When it comes to insurance coverage, the cliché says it all: The devil is in the details. Most physicians and benefit industry reps agree that patients need to understand even the tiniest minutiae of their coverage.
“Benefit or plan documents often get put into the kitchen drawer and never looked at or read,” says John Whitney, MD, an internal medicine and pulmonary specialist who is also manager and medical director for medical policy with insurer WellPoint. “One of the first things you can do is find them and read them.”
Unfortunately, some insurance plan documentation is so thick and laden with industry lingo that even the symbologist from the Da Vinci Code wouldn’t be able to tell whether, for instance, Imitrex falls under the coverage umbrella.
If migraine or headache sufferers don’t understand something about their benefit plan coverage, they should direct specific questions to their insurance companies, says Alan B. Rosenberg, MD, a physician and National Headache Foundation board member who has also served as an executive for a number of health benefit companies.
“Benefit plan documents are sometimes difficult for individuals to understand,” Dr. Rosenberg says. “But headache patients can always call their benefit plan customer service number, and most large benefit companies have online query processes. Electronically submitted questions, given that they are written, provide a response that is clearly documented for the beneficiary.”
The takeaway from your research should be an encyclopedic knowledge of exactly what your plan covers—the specialists and physicians that are in-network, any copay requirements, the cost of generic versus name-brand prescriptions, the kinds of treatments classified as medically necessary, etc.
Moreover, Dr. Rosenberg says patients filing claims should understand which benefit they are trying to access. This is particularly important as it relates to pharmaceutical or medical benefits, as these may be directed to different places. For example, retail or mail-order pharmacy benefits are generally covered through pharmaceutical benefits. Physician office appointments, emergency room visits, hospital procedures, physical therapy and diagnostic imaging are generally covered through medical benefits. To make matters even more confusing, some medications given to migraineurs in the emergency room or in-office may be covered through medical benefits, not pharmaceutical.
Patrick-Lake learned of these classifications first hand after undergoing Botox treatments for her chronic migraines. Her insurance provider covered the $500 injection procedure fee, but the $1,500 drug got billed in an area of coverage that had a separate deductible, Patrick-Lake says.
2. Get to Know Your Doctor
Headache patients need a physician who can do more than just diagnose and treat their illness; they need a true partner in care. Tackling both chronic pain and insurance authorizations demands a team effort.
“It’s about finding the headache specialist who will go to bat for you,” Patrick-Lake says.
Once you have located the right healer (chosen from a list of in-network doctors), it’s important to get involved in the continuum of care, from diagnosis to follow-ups. A good place to start is where many migraine and headache sufferers square off with their benefit companies—over the prescription medications used to treat their conditions.
Some patients find name-brand drugs more effective than their generic counterparts, while others don’t get enough triptans to cover all of the migraine attacks they experience in a month. In these cases, patients can find themselves digging deeper into their pockets—sometimes to the tune of hundreds of dollars per month—for drugs their payers won’t approve.
Merle L. Diamond, MD, headache specialist and president of the Diamond Headache Clinic in Chicago, says it’s unfair to penalize patients who don’t want to take generic drugs that might not work as well.
“We’re not Keebler cookies that all sit in the box and look the same,” she says. “Genetically, there are clearly distinctions in how patients respond to medication.”
Headache patients and their physicians, however, can often build a case for covering their preferred treatments. Not surprisingly, it’s all in the paperwork.
Both parties should ensure the medical records submitted to the insurance company properly reflect what’s going on. WellPoint’s Dr. Whitney suggests migraine and headache sufferers involved in complex care keep a detailed journal that meticulously documents the incidence and length of the medical issue, specific medications taken, other treatment interventions and side effects.
“It helps the doctor and demonstrates the [condition’s] severity,” he says, adding that the information can also be a valuable record of treatment when presented to an insurance provider.
And while it might be an uncomfortable conversation, patients need to speak openly with their physicians about payment and ways to save money on treatments if their coverage is limited or possibly denied.
Some offices even bundle treatments together to give patients more reasonable rates for care, though Dr. Diamond cautions “not all offices are that creative or willing to do it.” Be sure to inquire about all possibilities.
3. Study the Rules of the Game
Migraine and headache sufferers need to make every effort to understand how their care is evaluated so they can equip themselves to deal with unfavorable health care decisions levied by their insurance companies.
Most major health insurance plans base their policy decisions on credible scientific evidence published in peer-reviewed medical literature, Dr. Rosenberg says. Published clinical trials make a treatment more likely to be covered than one based purely on anecdotal testimonials.
But for patients with chronic pain, some physicians enlist a battery of treatments, such as acupuncture or magnets, that are not covered by a benefit plan.
“Individual doctors may try a lot of things to see what works with migraineurs,” Dr. Rosenberg says. “But health care companies are looking for more systematic evidence to see that a treatment actually works better than the placebo.”
Even medications that have met benchmarks required by the FDA can be sidelined by providers until they are fully vetted. For example, Botox for migraine relief is classified as an off-label therapy by some providers because of the dearth of studies demonstrating its effectiveness.
Dr. Rosenberg suggests checking a benefit company’s website for its coverage and medical policies to see if specific treatments are covered. He also recommends migraine and headache sufferers enroll in reputable, well-constructed clinical trials to evaluate newer treatments and advance the clinical evidence upon which providers base their decisions.
“If there’s good clinical evidence supporting a medical treatment, usually the benefits will follow,” he says.
Migraine and headache patients also have ways to appeal services that are denied coverage. Most major health insurance plans allow for both an internal review and an independent external review if a patient and his or her physician think a denied treatment is medically necessary. In addition, federal legislation passed last year, the Patient Protection and Affordable Care Act, entitles patients whose benefit plans are covered under the act to an independent review process.
However, be forewarned: There are limitations to what a patient can procure through the appeals process. For example, if a benefit plan explicitly states a provider will cover only a certain amount of a drug, that determination may not be subject to an independent external appeal, Dr. Rosenberg says.
“If a person starts by reading what’s in his or her specific benefit plan and if the treating physician submits the relevant clinical information, the appeals process is much more likely to be effective,” he says.
4. Don’t Go it Alone
Like other people with chronic pain, migraine and headache sufferers can be at a disadvantage when charting their course of care. In addition to pain, patients often struggle with work issues related to their condition, a lack of time and money, and other health ailments—all of which make it difficult to spend time skimming coverage packets and questioning claims representatives.
“Patients often say, ‘I’m too sick to take action,’” Patrick-Lake says. “But we have friends and family that can take action on our behalf. If we don’t, we will continue to be denied therapies.”
Strong patient advocates can help research health care plans, compare pharmaceutical prices, and speak with doctors and insurance companies on your behalf. It also pays to think slightly outside the box when choosing a resource. Patrick-Lake says people looking to switch health care plans or providers should talk to their doctor’s front-office staff to see which companies respond promptly to requests for approval.
“I want to know the staff ’s impressions on various insurance carriers because those are the folks processing claims on my behalf,” Patrick-Lake says. Navigating the United States’ convoluted health care system is a stressful process, but don’t become discouraged by missteps, bad news or what appears to be an endless uphill climb.
“I’m a highly educated advocate, and I still got a surprise last year of close to $2,000 in out-of-pocket expenses that I wasn’t expecting to pay,” Patrick-Lake says. What’s most important for migraine and headache sufferers is to keep lobbying for the benefits they need—whether that’s alternative therapies or specialist referrals—and not to take no for an answer, Dr. Diamond says.
“Patients need to be persistent,” she says. “Not just for themselves but for the care they need.”
If you need help paying for prescription drugs, try these NHF-approved patient assistance programs.
Price of Triptans
If health care costs are crippling your finances, you’re not alone. Take a look at the unsubsidized cost of a single dose of these commonly used triptans based on national retail averages.
Relpax (20 mg) - $34
Frova (2.5 mg) - $37
Maxalt (5 mg) - $38
Amerge (2.5 mg) - $43
Imitrex (25 mg) - $39
Generic Sumatriptan (25 mg) - $24
Imitrex Nasal Spray (20mg) - $61
Generic Sumatriptan Nasal Spray (20 mg) - $44
Zomig (5 mg) - $38
Zomig Nasal Spray (5 mg) - $53
Source: Consumer Reports
