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Denied: What Can I Do When Insurance Won’t Cover the Treatment or Medication My Doctor Suggests?

Patients with chronic conditions like migraine disease have been through this a zillion times: Your doctor has suggested a procedure or medication, but your insurance company says they won’t pay for it. It’s an incredibly frustrating situation to find yourself in, but what can you do? You might be tempted to find out the cost and try to pay for it yourself, but is there something else to try first? Yes, there is. Here’s what you need to know.

 

Appeal the Insurance Company’s Decision

Your doctor and his/her staff can help you appeal an insurance denial. By demonstrating the medical necessity of the proposed procedure, treatment or medication your doctor may be able to convince your insurance company they are obligated to pay for the cost of it. The request must be made in writing. Luckily this is a process doctors’ offices are intimately familiar with and most of them will do the work for you as a courtesy. If they don’t offer to initiate the paperwork for you, just ask them about it and offer your assistance to make it as easy as possible for them.

Negotiate Your Cost

Sometimes insurance companies negotiate better prices for their customers, leaving you to pay a higher cost if you pay out of your own pocket. That seems unfair, right? As individuals we don’t have the same negotiating power as a big group. Fortunately sometimes if you ask they will honor the group price for little old you. Maybe they won’t, but ask before you make arrangements for the treatment or procedure. The worst thing that can happen is they say no. It’s worth a shot.

Consider Alternatives

There are often generic alternatives to name brand prescription drugs that your insurance company will be more inclined to cover. While some of us have already been there and back with the generic medications available to us, sometimes doctors will suggest a name brand medication first. If you find yourself in this situation be honest with your doctor about your financial concerns and initiate an open discussion about more affordable options you could try before shilling out hard to come by money for a brand name drug.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • Katherine Linnell Lunn
    7 years ago

    I have an 8 year old son who suffers from migraines. My insurance company denied imitrex for his treatment. They stated that they do not cover ANY migraine medication for treatment….. What can I do?

  • Katherine Linnell Lunn
    7 years ago

    I agree with you and hopefully they will get the meds approved soon. In the meantime I guess we will have to just pay ALOT of money out of pocket. Awesome, I am just waiting for his appointment and then hopefully we can find something that can help him. It sucks that the kids have to suffer with this ;(

  • Richard M Stacy
    7 years ago

    I just pray she don’t get any cause when she does I feel soo bad at least they are doing studies to get the drugs approvedfor kids its moving in the right direction just way to slow!! My daughter sees dr markley he has a dry sence of humor but he is good

  • Katherine Linnell Lunn
    7 years ago

    Thats what I ended up doing. I paid $200.00 for a 6 day supply. My son was reffered to a neurologist there and he is also, scheduled to go to the headache clinic at Childrens hospital. I find it unbelieveable that there are no medications available for his treatment and that there is only one medication for children aged 12-18. That is horrible!!!! So, are they suppose to suffer because of it? I hope your daughter finds the relief she deserves!!! poor thing.

  • Richard M Stacy
    7 years ago

    It really sucks but the e.r for pain meds if it gets too bad is the only option unless you pay out of pocket for the drug instead of 30 you buy only 4 or 5 we paid like 35 bucks a pill and we got 4 just to see if we could break the cycle

  • Richard M Stacy
    7 years ago

    My daughter has had them for years there is only one drug covered for under 18 due to the fda. My daughter sees a specialist in worcester at the new england regional headache center and she does drug trails to help get the fda to approve some drugs for under 18

  • Katherine Linnell Lunn
    7 years ago

    They do not cover any migraine medication for children under the age of 12 and only 1 medication for children from age 12-18.

  • Diana-Lee author
    8 years ago

    I had the same experience with my insurance company and botox. I was lucky that my parents paid for it twice so I could try it. It didn’t help me, but it does help so many people that I’m very thankful it has finally been approved for migraines.

  • Ellen Schnakenberg
    8 years ago

    Diana, Thank you for writing about this – it is so very difficult when this happens. Frustrating as it may be, it is worth the trouble to exhaust every avenue before giving up on the treatment as an option.

    Botox was my insurance problem. This was years ago, and nothing we did worked. Dr Hutchinson comments with some helpful hints if this specific procedure is an issue for you: Botox Approval for Chronic Migraine: What Does this Mean? http://bit.ly/hPH7rb

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