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My Prior Authorization Didn't Follow When I Changed Pharmacies

In October of 2021, I began seeing a migraine specialist at a headache clinic. I shared my experience of switching to this doctor here, and my overall, I've been really happy with and grateful for the care I've received since the move.

For about the last year, I've been in a good groove of preventative and abortive migraine medication.

How have I been treating my migraine?

What has worked for me has included preventatively taking Qulipta as an oral pill daily (more on that here) and receiving Botox for migraine every 3 months. Abortively, my first line of defense for a mild or moderate migraine is Fioricet, and for a moderate to severe migraine is ketoralac intramuscular injections, of which I either administer to myself or have my husband administer to me.

How have my treatments worked for me?

This push and pull has prevented me from missing more than a few days of work for migraines over the last year, which is a huge improvement, and has allowed me to stay out of both the infusion suite at the headache clinic and the emergency room to abort destructive migraines.

How often do I see my doctor?

Because things have been at a status quo, I typically only see my doctor once every three months. We do a check in/update appointment, followed by the administration of Botox in my face, scalp, jaw and upper shoulders.

What happened at my last appointment?

During my last visit, my doctor casually mentioned that the speciality pharmacy in which I'd been filling Qulipta for the last 16 months was no longer gong to be filling migraine medication, and where did I want the prescription transferred to? At the time, I didn't think much of it. To be honest, this speciality pharmacy was a dream. They operated fully via text or web portal, my doctor sent them the prescription + refills, they texted me to tell me it'd been received, they received prior authorization from my insurance, found a zero dollar copay card for the balance, texted me the refill was ready, then shipped the refill to my house. The blue padded mailer would arrive monthly with no stress attached and I went about my day adding it to my weekly pillbox.

What did I think would happen?

So, after this note from my doctor on the change in pharmacy, I figured the same thing would happen. He'd send the new prescription to my regular pharmacy, one I fill almost all of my other medications at, they'd obtain prior authorization, I'd find a copay card, and we'd be back on our way.

No, friends. That's not what has happened.

What happened to my prior authorization?

The prescription was sent nearly two months ago after my visit to my doctor. The pharmacy told me they couldn't fill it until they received an approved prior authorization. Okay - normal procedure so far.

Friends, the prior authorization was denied. My insurance now required that I fail three other medications before they'd consider even reviewing an "Exemption to Coverage" form for my Qulipta. Now, there's several reasons I'm not on and haven't tried the three other medications before (more on that here) and so the kind people at my doctors office are appealing the prior authorization denial currently.

The problem? I'm watching as my supply of remaining medication dwindles down.

What is my doctor's office doing?

Again, the kind people at my doctor's office offered me a full month of samples of the medication, which has bought me some time... but without an approval, or with a delayed approval, I'm going to end up going without my preventative medication.

What do I do?

Now, as any migraine patient knows, sometimes preventative medications are more placebo than effect; however, I desperately do not want to find this out. And also, finding this out, needing to abruptly stop my medication through no fault of my own... it might be what's coming around the corner.

And I'm terrified.

If you've ever experienced something similar, I'd love to know how you navigated the situation - either of prior authorizations changing/being declined after you'd been on medication for a long time, and/or of abruptly having to stop preventative medication and how that went for you.

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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.

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