Insurance: Getting covered with headache and migraine

The community question was...

What would you recommend to people who are struggling
to get their insurance company to pay for their treatment/medication?

We've learned that insurance can be a big problem (examples - the triptan conundrum, and this poll).  It's not easy.  But once again, our visitors have risen to the challenge and offered some great advice!
Insurance for migraine and headache treatment?
Here are a few of the answers that were received.  First, some great basic tips:
  • It is absolutely essential to work with your doctor.  He may have to write letters every time you need more than what the insurance wants to give.  He is your best ally--work at getting him on your side; change doctors until you find one who will work with and for you. (Trudy, USA)
  • Be persistant.  I've learned that with large corporations if you have what you consider to be a reasonable request, SOMEBODY at that company will agree.  If you can get just one person on your side, it can make a world of difference in the response you get.  If you don't achieve success the first time, get that person's name and next time, talk to somebody else.  Keep doing that until you reach success.  It is amazing how one person can word it slightly differently but still absolutely true so you will qualify.  Its sometimes a matter of being creative -- truthful, but creative. (Mary, Canada)
  • I work for a insurance company.  I suggest the patient get involved in the process.  Call member customer services and ask for the medical policy on migraines so that you can she was is necessary in order to prove medical necessity of the medication.  Also, talk with your doctor to see if there is a medication that can be prescribed for a different ailment and just happens to help with headaches.  Another suggestion would be to go to a neurologist and have the neurologist find the appropriate medicine. (Ann, USA)
  • Persistance.  I have had migraines since I was 18 years old. I was told I had TMJ (jaw problem), then stress (the fallback for when doctors don't know), back problems, and finally mental issues.  I was fitted for a bite guard, put on muscle relaxers, sent to physical therapy, an allergist and even had to try a medicine for irritable bowel syndrome.  In my late twenties I was finally diagnosed with migraines.  For each of the above problems I kept going back when the meds didn't solve the problem.  Don't wait for months before going back, a few weeks is enough.  If your doctor sees what you have IS a migraine, he/she will work hard for you to see that the insurance covers what you need. (Sandra, USA)
And here are a few more tips, when your insurance just isn't cutting it, or nothing else seems to be working...
  • There is an appeal process where you can appeal the decision of the insurance company.  It is worth a try.  Also, drug companies may be able to help with people who have limited incomes. (Kathy, USA)
  • Many companies have reduced pricing programs for qualifying patients.  Go to their websites and follow links to special pricing. (Louise, USA)
  • The ONLY way I have found to get my insurance company to pay for meds I use for migraines off label is by having a medical malpractice lawyer send a letter to the company with doctors' letters stating that the costs of paying for my meds would be far less than the cost of paying for the ER and/or in patient hospital care I'd need if they deny my meds.  This has always worked for me because money is the bottom line with all insurance companies.  (Lawyers work because insurance companies don't want to have to deal with lawsuits for withholding necessary meds.)  I've also heard from friends if you can't afford a lawyer you can enlist the aid of the attorney general's office and they'll sometimes do a power play on your behalf.  And if you can't get the attorney general, any congressman you can get to help you out may do the trick.  If you don't know who these people are, just call your local League of Women Voters. (Meredith, USA)

Thanks everyone, for the excellent ideas!  I think one of the most important concepts here is PERSISTANCE.  Don't just let things go.  Remember, when you're helping yourself, you're also helping many many other people who may find themselves in the same situation.

An individual at an insurance company may give you all kinds of reasons why you can't be covered.  Check out those reasons.  Get a copy of the policies of the company, so you can see for yourself what it says.  Is there really a law that is limiting the company?  Do they have so-called medical experts telling them something that may not apply to you?  Check it out.  Don't give up.  It's time to fight back.

Summary - insurance help

Insurance companies provide a helpful service, and many people in those companies genuinely want to make the world a better place.  But sometimes the system doesn't work, and sadly sometimes it does come down to money.  Here's a summary of what we've learned:

  • Be persistant.  Don't give up!
  • Be honest.  Dishonesty will come back to haunt you.
  • Work with the insurance company.  Be involved in the process, don't just be passive.
  • Find a doctor who is willing to take the time to help, and who understands your medical history and the insurance system in your country.
  • Be patient
  • Get the names of people you talk to on the phone, and try talking to different people.
  • Be sure you have a proper diagnosis
  • Check to see if there is an appeal process.
  • Check if the drug company has a program that you might qualify for.
  • If all else fails, start going up the ladder of authority.  Talk to your representative in the government.  Talk to someone higher up in the insurance company.  Consider getting a lawyer (I consider this a last resort because it makes the process far more adversarial.  Everything works best when people are your friends and migraine is your enemy!)
  • Be informed - understand the latest information about migraine, cluster, whatever you have, and the related drugs.  This is a great place to keep up to date!  Sign up for HeadWay and stay up to date at the Headache and Migraine News Blog!
That's all for this community question!  There's a new question now - go to this page to give your advice!

Image © Yury Shirokov | Dreamstime.com