Migraine Treatment Insurance Barriers: CHAMP Resources (2023)

You're not alone

Living with a chronic and painful illness is challenging and can be isolating. Know that you are not alone. You are an important part of a community that is strong and powerful. You deserve to have access to the treatments prescribed by your doctor.CHAMP participantsare here to support you on your journey through the ever-changing insurance landscape.

Access issues explained

Insurers often hide behind unethical practices to deny patients access to treatment. The following are the most common access issues (or barriers).

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CHAMP Financial Assistance Guidelines for FDA Approved Drugs

Many pharmaceutical companies and device manufacturers have patient financial assistance programs designed to make new treatments available to patients while insurers make their coverage decisions. To help you navigate these programs, CHAMP has createdfinancial aid guidesthat provide easy-to-understand information about whether or not you have private or legal insurance.


Savings programs are generally not available if your health insurance is provided by state or federal programs such as Medicare and Medicaid. This is because the federal government does not allow people enrolled in these insurance programs to benefit from interim assistance or copayment programs. If you are having trouble getting your treatment covered by Medicare or Medicaid, contact the manufacturer who will help you determine eligibility for other financial assistance programs.

Prescription coverage and forms

Every insurance company has a list of prescription drugs they cover. This list is called a form. Within an formulary, drugs can be categorized into tiers that determine how much of the cost the insurer will cover and how much you will have to pay.

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Forms are usually reviewed by an insurance company once or twice a year. Even if the FDA approves a new drug, insurance may deny coverage until the formula is verified. This leaves patients with long periods of time before they can try a newly approved treatment. When a new drug is placed on an insurance company's formulary, it may be placed at a tier that requires a large co-payment from the patient (this is known as an "adverse tier").

Patients can request a waiver form. In addition, there are several prescription drug savings programs that can help significantly reduce your prescription drug costs.

priority authorization

When your doctor prescribes a treatment, test, or procedure, many insurers require an extra step (or hurdle) of verification. This is known as pre-approval. Coverage may be denied if a patient and their medical practice do not go through the pre-approval process or if the decision is negative.

Prior authorization creates barriers to entry due to the bureaucracy the patient must go through to obtain authorization, delaying medical treatment. If prior approval is not obtained prior to any test or procedure, the total cost may be the sole responsibility of the patient to pay for these services. If a patient is turned away, the decision can be appealed, further delaying access to treatment. The process of appealing a denial can be stressful and may result in some patients giving up recommended treatments.

Therapy Step/Failure First

When your doctor prescribes a new treatment, insurers may adopt a practice called step-or-fail therapy. Essentially, they require you to try and fail one or more medications before your new prescription is approved. Even if your new prescription is on your insurance company's form, failing first can be a barrier to entry. Step therapy may be required to obtain prior approval.

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In some cases, insurance companies will accept a medical certificate (letter from your doctor) proving that you have taken the necessary steps beforehand. Other times, you'll need to keep detailed records of the treatments you've tried, how long you've used each medication, any side effects, and the reasons you stopped treatment. Worst case scenario: Your insurance company may require you to take medications that you've already used, are ineffective, or even had negative side effects before approving a new treatment.

non-medical bill of exchange

Another prescription barrier is called non-medical switching. This happens when your insurance company forces you to switch to another drug in the same class. The drugs are not identical and the change is forced for the insurance company's financial benefit, ignoring the potential negative impact on you, the patient.

comprehensive help

Die Patient Advocate Foundation (PAF)migraines are importantThe program provides FREE one-on-one browsing services and support for patients with headaches, migraines, and cluster disorders. PAF has extensive experience in working with patients with access problems. Whether it's a refusal of treatment or a seemingly meaningless medical bill, PAF's trained staff will work directly with you to understand the issue, gather information and help you file an appeal or complaint.

Become a case manager:

  • Work with you before the end of financial assistance programs to ensure continued access to prescription drugs.
  • Verifying your eligibility and assisting with enrolling in prescription drug assistance programs
  • Negotiate expensive medical bills related to your treatment

For a complete list of services offered, seemigraines are importantProperty.

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fill in and sendOnline application support applicationand a case manager will contact you within 48 hours.

PAF also offers the Migraine CareLine, a dedicated telephone line and online resource. Call us directly at 1-866-688-3625 or visit ushttps://enxaqueca.pafcareline.org/for help with insurance denials, disability claims, financial resources and more.

online communities

The following online communities of CHAMP participants can provide a forum to connect with others who have experienced and overcome similar access issues.

Appeal letter template

Navigating insurance approvals and appeals often requires sending letters of support. Below are some templates to help you compose your letters and make sure you include all the necessary information.

patient's rights

It is imperative that you are proactive when designing your care and treatment plan. Whether you've just been diagnosed, are starting a new drug or device, or are nearing the expiration date of a financial assistance program, you have rights when it comes to insurance coverage.

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1. Devices for Migraine Survey Results Webinar
(The Headache & Migraine Policy Forum)
2. Migraine State of the Union
(American Migraine Foundation)
3. HDPAN Migraine Advocacy Journey
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4. Migraine Disability VA Claims (Headaches) in 2021 [What You *REALLY NEED* to Know!]
(VA Claims Insider)
5. Neuroscience Updates, Fall 2020 Series – Migraine: Management and Current Treatment Options
(Norton Healthcare)
6. Medical Devices for Migraine Survey Results Webinar
(Migraine Meanderings)
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