When Health Insurance Makes You Sick
Recent changes have had a tremendous and far reaching impact on what health insurance companies charge and how much they cover for services provided. Migraineurs are not only living with extreme pain but are now dealing with enormous stress and anxiety related to no longer being able to afford the effective medications they have taken for years. They may also be cut off from accessing FDA-approved treatments for migraine. As someone experiencing this, I am left wondering if the purpose of my health insurance is to insure that I’m sick.
Quantity limits
I’ve never had to choose which days will be my ‘well days” and which days I will have to be bed-ridden. However, in recent months, perhaps in response to the STOP act, my health insurance company placed arbitrary quantity limits on medications I have been taking for years. Literally, I have been taking these same medications – at the same dosages – for over five years. Now my health insurance company has decided they will only cover 1/6 of the amount I’ve been taking. Of course, I could pay out of pocket but that would cost me nearly $600 a month.
Like many others, I received sudden notice of this decrease in allowed quantity and was left struggling to manage my pain with only a fraction of regular medication. This situation causes a great amount of stress which is a classic trigger for many migraineurs.
Botox: New limits and increased cost
Some insurers have decided to place a strict limitation on the frequency of treatment. For those of us who have been taking Botox for years, we may have found that by 12 weeks, the efficacy wears off and that 10 weeks is far more effective. The 10 week cycle has been covered for years. Personally, if I am forced to switch to a 12 week cycle, the final two weeks will be accompanied by a dramatic uptick in migraine severity, often leaving me bedridden. Additionally, my health insurer has placed Botox in a different category of medication, which means my out of pocket cost has tripled. This is a key part of my migraine treatment protocol, and I’m unsure how we will afford such a massive expense.
Guinea pigs are we: Gammacore and CGRP
With newly FDA-approved treatments for migraine like Gammacore and CGRP, health insurers are slow to decide whether and how much to cover. For instance, even though Gammacore has been FDA-approved for migraine, I was denied coverage on the basis of a “lack of scientific evidence.” This is illogical given the fact that FDA-approval is based on scientific evidence. I was given the device on a trial basis – just long enough to learn that it was effective for me – and then was denied coverage for it by my health insurer.
Similarly CGRP, which holds great promise for many with migraine, is being given out for free on a two-month trial basis. However, after the trial, there is no telling whether health insurers will cover the expense. We do know that at almost $7000 per year, the expense is likely out of reach for most if not covered by insurance companies.
Appeal and appeal again
After you’re finished stomping around and yelling at the walls, the best recourse for dealing with an insurance company denying coverage is to file appeals. And then when you get denied, because you most likely will, appeal again. Make certain to gather as much evidence to support your case as possible. This will include a list of your medications, a history of your visits to your migraine specialist, a letter of support from the specialist, and your own statement documenting your need. It may also help to reach out directly to your appeals analyst and speak with them by phone. They often have a harder time turning you down if they speak with you in person and remember you are an actual person.
Be flexible
It is truly infuriating to have to find a new solution when we already have something that effectively manages our pain. However, with all of these changes in cost and limitations, it is possible that your appeals will be declined in the end. As hard as it is to consider, we might have to adjust our treatment approach during this difficult time, or face the equally daunting challenge of finding the money to pay out of pocket to continue to receive the old, effective treatment.
Are you having challenges with your health insurance company? How are you handling these changes?
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