Migraine Treatment: Understanding Your Insurance Formulary

Patient Expert & Health Professional
Medically Reviewed

Part of good migraine management is understanding your health insurance benefits. Those benefits often include some coverage for prescription medication and durable medical equipment. It isn’t unusual to discover that your health insurance coverage is at odds with your doctor’s recommendations. That’s because health insurance companies and physicians have different agendas. Physicians make decisions based on the best interest of the individual patient. A health insurance company’s primary goal is cost savings.

The formulary

When it comes to prescription medication, each insurance company has a formulary. This formulary is a complete list of covered medicines, including quantity limits and coverage rates. The different rates are called tiers. Tier 1 medicines are covered with minimal out-of-pocket costs to the patient. Each insurance company will have multiple tiers, with the highest tier requiring the greatest out-of-pocket expense. Medicines not listed in the formulary are not covered at all. These medicines are available only to patients who are willing and able to pay the full cost.Each insurance plan is required to provide you with a copy of the formulary. Most are published online, but may not be easy to find or understand. You do have the right to request a paper copy. You may also contact your insurance plan by phone to clarify the coverage for specific medications.

Quantity Limits

As part of the formulary, there are also quantity limits on certain medications. It’s not always clear why the quantity limits exist. They vary from one company to another. If you have migraine, you’ve probably already encountered these limits on triptans. The limits are so restrictive that even patients who strictly adhere to treating attacks only 2-3 days each week often find themselves with an insufficient supply.These limits can be appealed through a Quantity Limit Exception request submitted by your doctor. If approved, your out-of-pocket cost does not change tiers, but you will pay more for the increased quantity. If you normally pay $40 for nine triptans and you are approved for 18 instead, your out-of-pocket cost could double.

Medical Necessity

When benefits and physician recommendations conflict, most insurance plans have an appeals process. If the medication is not covered at all, and a compelling argument is made that only that particular medication is warranted, then insurance companies will sometimes agree to cover it.Even if your insurance company agrees to cover a medication, you may still be faced with out-of-pocket costs. When a formulary exception is granted, the medicine is usually covered at Tier 4 or higher. You may still be expected to cover 60 percent of the cost or more. In this situation, you may want to consider bypassing your insurance benefits altogether.

Appeals and exceptions

Some plans allow the patient to submit an exception request or appeal, while others will only accept requests initiated by a doctor. Plans vary on their rules about who must initiate the paperwork.It can be helpful if your physician is willing to assist with this process. However, physicians can often wait on hold up to 30 minutes for each request, trying to help a patient. There is no reimbursement for this time. Doctors who are willing to complete these authorizations do so without being paid for their time. If you are fortunate enough to have a doctor willing to help you in this way, please express your thanks.Some patients get better results when they initiate an appeal or exception request. This is one time when advocating for yourself can mean significant cost savings. Ultimately, you are the customer. Don’t hesitate to speak up, ask questions, and state your case when necessary.

Opting out

Sometimes it makes more economic sense to opt out of using your insurance benefits. It’s worth taking the time to shop around and check out discount programs before blindly filling a prescription assuming that your insurance coverage is the best deal around. It is rare for all prescribed medications to be included in the insurance formulary. Others may be covered, but the out-of-pocket costs are outrageously high. That’s when using a discount card helps reduce costs.Some discount plans have apps you can use to check the price of a medication while still in the doctor’s office. If the estimated cost is more than you can afford, you and your doctor can discuss alternatives immediately. You can even ask your pharmacy to keep a copy of your discount card on file to be used for specific medicines. This extra step can save thousands every year in prescription costs.

You’re in control.

Health insurance is a valuable tool for good migraine management. It takes some effort to learn about our benefits, estimated out-of-pocket costs, and the process for requesting exceptions. Ultimately we are in charge of our health care. Take the initiative to educate yourself about your health insurance benefits, but don’t stop there. Not every treatment will be covered by insurance. Discount cards and patient assistance programs can supplement or replace insurance in some situations. Take charge of managing your prescription costs by checking prices, asking questions, and requesting help from your doctor to obtain exceptions when needed.

More helpful information:

No Insurance Often Means Substandard Migraine Treatment