Medicare Denied My CGRP
Last updated: October 2022
Over the past couple of years, we have seen several emerging medicines and devices for migraine management. Sounds great, right? So why are so many unable to access treatments?
Those who live with migraine disease are tired of receiving low-quality treatments. The cost of medicines should not be a barrier to better health.
I was among those migraine warriors hoping for a miracle when I learned the first round of FDA-approved CGRP therapies would soon be available.
Would my insurance let me get Emgality?
My chronic intractable migraine requires me to take several different preventatives and acute medicines. When I moved to Texas in 2021, my headache specialist and I decided to add Emgality to the toolbox. However, my insurance plan deemed it wasn't medically necessary and denied me.
Hearing my medication would not be covered added another level of stress. I knew there was a strong possibility of denial, so my provider and I had to develop several alternatives should our first choice become inaccessible.
What can you do after an insurance denial?
First, call your health plan and inquire why your medication wasn't covered. Most times, a prior authorization is needed.
If your insurance plan requires prior authorization on treatment your doctor believes medically necessary, they need to support the claim to get you covered. The doctor completes a PA form to submit to the insurance company. The process can take up to 72 hours to hear a determination. However, an urgent request can always be submitted, requiring your health plan to review within 24 hours.
In my case, all I needed was a prior authorization, and I received approval for Emgaility.
What is step therapy?
Often enough, plans insist on step therapy. This means you must first try a less expensive drug on the formulary (also called a drug list) that has been proven effective before moving up a "step" to a more expensive drug.
If you can prove the failure of those steps, you may qualify for the newer requested medication. I have even had prescribers send a letter stating I have already gone through the required steps, resulting in approval.
Here are some tips:
Get a copy of the formulary. It can be found on the website or mailed out. If needed, your provider can request a formulary exemption. Ask for the drug list before choosing insurance coverage. I extensively went over all my current medications and new migraine treatments I may want to try in the future. I did not want any surprises.
Keep all your records. You never know when you may need to show proof of failed past treatments.
Reach out to the pharmaceutical company. Some offer assistance programs. Paying out of pocket is out of the question for most of us. An alternative option is to invest in a health savings account. It will allow you to put aside money to pay for approved medical expenses.
Remember, you are not alone. Many resources are available to help with insurance hurdles, navigating insurance, medication denials/appeals, and more.
Check out these resources:
- American Association of People with Disabilities
- Coalition for Headache and Migraine Patients (CHAMP)
- Migraine.com (You're already here! Check out what others have to say in the forums.)
- Coverage Rights
- U.S. Pain Foundation
- The Patient Advocate Foundation (PAF) Migraine Matters program
Have others downplayed your migraine pain?