Why Does My Insurance Get to Determine My Treatment Plan Instead of My Doctor?
In the fall of 2021, after experiencing several emergency trips for unbearable migraines, I found a migraine specialist who was willing not only to think outside the box, but to look at me as a person and not just a patient. This was empowering and encouraging, and I’m grateful to report that for 2.5 years, I had very few migraine days, they were all stopped by my as needed abortive medication, and required no trips to the emergency room.
What preventive treatment was I using?
One of the pieces of that migraine medication puzzle for me was a medication called Qulipta. I was on this medication for 3.5 years, and it did exactly what it was supposed to do, with a relatively small side effect profile - which is almost unheard of for me. In July of 2023, I underwent surgery to repair a hernia in my esophagus, and I woke up with a terrible migraine which took two weeks and several cycle breakers to go away.
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Why did I have to try a new preventive?
Now, at this point, my doctor recommended that I try something besides Qulipta as a preventative - something like Emgality, Aimovig or Ajovy. It happened that these were the medications my insurance recommended “trying and failing” first before taking Qulipta - a medication I’d been paying for with a patient assistance program card since I started taking it. We agreed at that appointment I’d switch to Emgality, and discussed the risk/benefits of the change, as well as how long it should take to work.
When did my migraine attacks change?
Things mostly stayed status quo, until November 2023 when I was diagnosed with an infection called bacterial meningitis, and one of the most prominent symptoms I experienced was a skull crushing migraine that ended up lasting 14 weeks. My migraine specialist and the hospital neurologist worked tirelessly using IV medications to relieve the pressure in my brain and therefore the unbearable migraine pain, but without much avail. This is when I finally gave in and was admitted to the migraine ward at a hospital in my area - an entire floor for migraine patients who are trying to find pain relief and the right set of medications and symptom management. During this stay, I completed the DHE protocol, and did get some migraine relief.
How did my treatment change as a result?
In a follow up with my migraine specialist, we agreed that it made sense to switch back to Qulipta, as that had been working for the most part and the Emgality clearly wasn’t doing much, if anything, to manage the terrible pain I’d been in. I had one bottle left from my last use of the medication, and when I ran out, I found out that my insurance denied the doctors request to re-prescribe the Qulipta medication.
When can I get back to Qulipta?
My doctors office gave me a month's worth of samples and pursued two appeals to my insurance back to back, but ultimately lost. My insurance is now requiring me to try and fail both Ajovy and Aimovig before they’d consider approving Qulipta. As each medication can take several months to make a difference, this step therapy trial is both agonizing and terrifying for me - going from 14 weeks of an intractable migraine to migraine relief to losing one of the medications that has sustained my relief - it’s really scary.
Have you ever dealt with your insurance denying prescriptions that your doctor decided were best for you? If so, how was the switch for you?
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