Have you ever had your insurance company impose limits on your Migraine medications, or refuse to cover them at all? Many of us have. Is it legal for insurance companies to countermand our doctors' prescriptions? And what can we do about it?
In the summer of 2007, my insurance company suddenly came up with a new policy: after three years of problem-free coverage, they announced that the new "fill limit" for Imitrex was four tablets per month. I was having an average of three Migraines a month. However, some months I had more. Some Migraines take two triptan doses to abort; some come back after aborting for a number of hours. The number of Migraines I was having at that time was a low for me. A few years previously, before I started using abortive medications, I had been having 12 to 16 Migraines per month. I used my Imitrex, as prescribed, at the first sign of a Migraine, and that was one of the reasons I was doing so much better.
What's more, the Imitrex came in a nine-tablet blister pack. In order to receive four tablets, I had to find a pharmacy willing to split the blister pack. I called eight pharmacies; no one would do it. I had my doctor call in a statement of medical necessity. Response: "Sorry you can only have four per month; the average person only needs four per month." In order to get any Imitrex at all, I had to pay out of pocket for the remaining five tablets in the pack. My prescription (which had cost me a $50 co-pay) cost me $185 - a $50 co-pay on four tablets, then $135 for the remaining four tablets.
This is probably a familiar story to many of you. I have seen dozens of cases of of patients on this site having their triptans limited by their insurance companies, so that they can't to afford the medication they need to function. In my case, I paid out of pocket for the tablets three times, sent in several letters of medical necessity, and suddenly the company changed its policy to nine tablets per month. I am still in the midst of the appeal process, two and one-half years later, to get reimbursement for the times I had to pay part of the costs out of pocket. I'll let you know how that goes, if I ever get a resolution.
What right do insurance companies have to tell us how many triptans we need or should take? If they try to prescribe for us, over-riding the prescription of our own physician, aren't they practicing medicine without a license? Or if they have physicians reviewing our prescriptions, aren't those physicians committing malpractice by treating patients they have never seen examined and whose complete medical records they have never reviewed?
These arguments sometimes work to pressure insurance companies into increasing medication fill limits. In many cases, being a squeaky wheel and making too much of a fuss to be ignored will get you results. You can ask your insurer for the names, business addresses and medical license numbers of their reviewing doctors and write to the doctors' state medical boards. Would the claims that they are committing malpractice by limiting your triptans stand up in court? Maybe not. Will they get your insurer's attention? Most likely.
The problem is threefold. In the first place, for-profit insurance companies exist to increase profits to their shareholders. They increase profits largely by limiting what they pay out. Even not-for-profit insurance systems try to increase their bottom line by denying claims. There are basic conflicts in having our health care coverage depend on a for-profit insurance risk model, rather than having a model where health care is available to all, according to need. We get insurance, and we see it as a way to cover our health care costs - that's what the insurance company literature and advertising promises. Once you start dealing with claims, you see that the insurer's idea of why they exist is quite different.
In the second place, since the advent of managed care in the US, states have changed their laws. The insurance law is different in each state, but all the cases I've read indicate that insurers are permitted to review, and sometimes override, the prescriptions of our own physicians - in the name of limiting costs. The insurers would tell you, that they are not limiting our care; they are merely limiting how much of that care they will pay for. The insurance company's relationship with you is by contract - you, your employer, or some combination of both, pay for the coverage and in exchange, the insurer sets contractual limits on what they will and won't pay. In reality, these limits will control how much care people can get, given the sky-high costs of health care compared to average income.
I think there's a third branch of the problem - lack of general knowledge of Migraine disease. In the midst of my battle with my insurance company, I screamed at their representative "You wouldn't tell a diabetic they could only have their insulin half the times they need it!" Actually. I have read of many diabetics whose health has been seriously compromised by insurance company limits on their care. Migraine is problematic, however. Migraineurs vary widely in how much medication they need in a given month, and a treatment that works for one person won't work for another. A decision to limit medication based on averages will not help most Migraineurs - very few of us are "average."
We have a shortage of truly qualified Migraine expert physicians, and if we see that shortage in practice, how much more of a shortage must there be in the world of insurance review? How many reviewing physicians know much of anything about Migraine? The problem is not limited to triptans - there are many Migraineurs who find that the one medication that works for them as a preventive won't be covered by insurance - because Migraine prevention is an off-label use of that medication.
How can we deal with these limits? The insurance company's decision can be overturned, by a showing of medical necessity. How do we show medical necessity? We need to get a detailed statement from our physician, listing how frequent and severe our Migraines are, detailing the effects on us, in terms of disability, mentioning the risks of leaving Migraines untreated, stating what medications are effective and which are not.
When the insurance company refuses your medication, you must prepare for a fight. If you can afford to, go through the appeals process at the insurance company. Get the names or employee numbers of everyone you speak to, and document the day and time of your phone calls, as well as what they told you. Present as much evidence as you can of your condition and your treatment needs. You may need to write the statement of necessity with your doctor. Don't be surprised if your appeal fails, and the insurance company refuses to reverse itself. You must complete your appeal before you can take the issue to your State Insurance Commissioner.
Call the Insurance Commissioner early on, and let the insurance company know you are calling them. In most cases you will have to have exhausted all your avenues for help at the insurance company before the Insurance Commissioner can help, but calling ahead of time will give you better information about what to do than you would get from the insurance company. While you go through the appeal process, you will be helping to educate the insurance company, and the Insurance Commissioners, about Migraine.
You may need to take the case all the way to court. The more people take these cases to court, the more of a precedent will be set for meeting Migraineurs' medication needs. I would love to see lots of courts ordering insurers to pay for Migraine medications. A class action lawsuit could have a big impact here, brought by a group of people who had been denied medication, against an insurance company or group of companies.
Each of us who is a squeaky wheel with the insurance companies can make a difference for the rest of us. If more and more Migraineurs speak up and demand the coverage they need, from their insurers, from the Insurance Commissioners, from the courts, the companies will be forced to change their policies.