5 Ways to Get Better Insurance Coverage for Migraines

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Update Date 11/05/2020 . 5 mins read

Individuals who suffer from migraines usually experience symptoms which are often misunderstood and downplayed by the general public. In severe cases, these symptoms can negatively affect daily life, especially when it comes to performing chores or work-related duties. 


To compound this, select insurance companies (who do provide coverage for migraines) tend to make compensation for migraine treatment more difficult than it should be. For example, some may include specific clauses which require you to prove that your migraine has indeed become worse over a specific period of time before they can complete the process of compensation. To avoid having to deal with this situation, here are a few ways to help you pick out the best insurance coverage for migraines.

Gain Complete Understanding of Your Personal Insurance Policy

If you do not have this with you already, make a formal request for a copy of your personal insurance policy. Your policy will be able to help you understand its coverage for migraine care, inform you about your policy expiration date, the requirement of prior authorisation (PA) for receiving services and migraine medications, as well as the requirement of a referral letter when setting up an appointment with a neurologist. 

This will also help you gain a better understanding of the financial aspects of your policy. Most insurance plans would require you to pay a premium instalment by a stipulated due date in order to keep the coverage active. Should one fail to pay this premium in full by the due date, and its subsequent grace period, the insurance company may then opt to suspend or cancel your coverage altogether. As a result, the costs of treating your migraines, depending on its severity, may involve expenses for medications, doctor’s appointments, and medical examinations which will have to come out of your own pocket. The three notable types of out-of pocket costs include a deductible (a preset amount you must pay before insurance coverage kicks in), a co-insurance (an amount for services you must pay after a deductible has been agreed upon, and usually involves a percentage), and a co-payment (a preset, flat rate for services after a deductible has been agreed upon).

Look Out for Any Special Coverage Requirements

Now that you’ve gained a complete overview of what your insurance policy coverage entails, be on the lookout for any PA requirements that you must fulfil before the insurance company compensates you for migraine treatment or medications. Some insurance policies may often include a clause that requires you to undergo a thorough evaluation from a neurologist prior to receiving specific migraine medications. Alternatively, other insurance policies may include a clause that requires patients to be prescribed medications in a particular order so as to achieve certain outcomes.

In most cases, your doctor’s office will be responsible for submitting the PA, seeing as they will also need to demonstrate that a certain treatment modality or medications is required. With assistance from the staff at your doctor’s office, ensure that all documents are completed with haste and accuracy, so as to enable the document processing to begin immediately. 

Stay on Top of All the Important Deadlines

Apart from starting the PA submission process early, it is also vital that you are aware of all submission deadlines, as this will help you avoid any last-minute discrepancies. If for some unexpected reason, urgency is required for your submission, do find out beforehand as to how you can expedite the process to meet the deadline.

Also, do not be afraid to ask for help. If you must, seek the assistance of a case manager, who in general will be able to help you navigate the intricacies of a claim submission, free of charge. Similarly, if your insurance coverage is provided by an employer, seek the assistance of the human resources department, who will most likely engage the services of a dedicated company case manager to push through your submission.

Obtain a Copy of Your Insurance Company’s Formulary

To preface, a formulary is most commonly recognised as a list of medications. In the context of an insurance company, a formulary would mean the list of medications which are covered under one of their policies. Therefore, if you are depending on a doctor’s prescription for medications, this is a must-do. This is mainly due to the fact that insurance companies usually evaluate their formularies on a yearly basis for migraine treatment.

And while your doctor’s office can obtain this information on your behalf, it is best that you seek it out personally. Taking into account that there might be unexpected delays in obtaining this information, seeking it out personally might just be able to spare you from potential surprises the next time you intend to make a claim. While you’re at it, do also speak to your doctor about the medications that are not covered, and the assistance that you may require in ensuring that they are covered.

Claim Denied? Appeal if it Feels Justified!

There might be a possibility that the insurance company denies your claim even if you have adhered to all the requirements of the submission process. This may be due to a variety of reasons, such as the medications or a treatment being deemed “medically unnecessary”, your migraines starting before you purchased the insurance coverage, or the treatment administered to you is considered as “experimental” or “investigative”.

If you’ve taken these factors into account, and still believe that you deserve compensation for your migraines, proceed to appeal the decision. This process begins with you first filing an internal appeal. This appeal submission is, in most cases, supplemented with documents that explain the denied benefits, an appeal letter to your insurance company, and a letter from your doctor explaining why you need certain medications or treatment modalities. Once you submit this appeal, it is within your right to request for an external review as well. This refers to the appointment of a representative who is aware of your medical condition, for the purpose of filing an external review on your behalf. This review will primarily include two key factors – disagreements between yourself and the insurance company on medical judgement, and disagreements as to whether the treatments were “investigative” or “experimental” in nature.

Last but not least, never be afraid to seek help. Dealing with migraines can sometimes make you wish that you were curled up all alone in a dark room, trying your best to sleep the pain off. Take comfort in knowing that you are not alone in this fight, and that you will be duly protected if your migraine’s severity qualifies you under the insurance policy.

Hello Health Group does not provide medical advice, diagnosis or treatment.

Hello Health Group does not provide medical advice, diagnosis or treatment.

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