Why Does My Insurance Company Play Doctor with My Migraines?

Insurance companies are determining when and if we need migraine medications.

Posted Nov 25, 2020

Will I run out of my migraine medication if I take a pill/injection now? What if I run out before insurance will cover the next refill? My doctor tells me to take the medication at the first signs of migraine, but I don’t dare; what if it’s even worse tomorrow?

TheVisualsYouNeed/Shutterstock
Source: TheVisualsYouNeed/Shutterstock

Those who suffer from migraine and any chronic illness face these critical questions over and over again. When researching pieces of literature for my recent book, I encountered character after character, speaker after speaker, facing this very serious dilemma. I know I have — in fact, just today.

Changing Dosages for Prescriptions

After picking up my refill for Ubrelvy (a new acute medication for migraine), I noticed that there were so few pills. I returned and asked the pharmacist if my doctor had written the script for only that number and was coldly told at the drive-thru window, “No, it was written for 30 pills, but your insurance will only cover half of that." The next line was better yet: “You should only be taking it when needed.”

All the pent up frustration from people’s lack of understanding of this disease, the built-up weariness from the number of days I had needed the medication of late, and the rage at the insurance company ruling as if they know better than the doctors and patients when and how often medication is needed when dealing with a chronic illness swirled in my head at that moment.

However, I bit my tongue, drove to the nearest parking spot at the pharmacy, put the car in park, and cried on the steering wheel.

Ubrelvy is one of the new CGRP inhibitors and recently became available orally; even the prescription reads, "Take at the first sign of migraine." The FDA also includes this information for the drug's administration: "If needed, a second dose may be taken at least two hours after the initial dose. The maximum dose in a 24 period is 200 mg" (www.drugs.com/pro/ubrelvy.html). 

Despite the objections of an overwhelming consensus of insured Americans, as health care costs have risen, insurance companies have increasingly used their power to alter doctors' prescriptions and override patients' treatment decisions.

Prior Authorizations

Already, it’s easy to find migraine patients struggling to navigate the complicated web of permissions and designations required to gain coverage. Patients struggle to endure the lengthy prior authorizations, the requirements that force doctors to get permission from their patient’s insurance provider before being able to prescribe a drug.

Switching

One example of insurance company interference—legal in every state—is non-medical switching, when an insurance provider stops covering a medication, increases its out-of-pocket costs, or implements other benefit utilization barriers so that the medication is no longer affordable for a patient. When insurance companies can use their power to alter prescriptions and dictate treatment decisions, doctors' autonomy erodes, which can then undermine the mutual trust that is the foundation of the doctor-patient relationship.

Choosing Between Drugs that Work Cooperatively

When seeing my neurologist for a regularly scheduled appointment for Botox (every 12 weeks because, even though many studies and my own experience for years indicate the positive effects of Botox last 9 to 10 weeks, the insurance companies have determined they know better), she informed me she had some difficult news. At some point this coming year, insurance companies were planning to limit patients to either Botox or a CGRP. 

Wait, does this make sense? Certainly not for the patient, who has found the combination effective in reducing the number of migraines per month, but does this decision even make sense for the insurance companies, who will eventually pay more for emergency care, migraine clinics, and treatments, including nerve blocks, and more to get the patient through to the next Botox administration:

“Some refuse to cover CGRP drugs if they’re used in conjunction with Botox—a common migraine treatment—since they have not been studied together, even though clinicians and patients are finding success with the combination. People without insurance face an even more difficult path, since they’ll bear the brunt of list prices when assistance programs run out” (Ducharme).

Step Program

Sharona Hoffman, professor of law and bioethics at Case Western Reserve University School of Law, offers that step therapy is driven by a single motivator: saving costs. Hoffman, who’s written about the legal and ethical implications of step therapy, says that sometimes step therapy often leads patients to take generics instead of brand-name drugs. But these policies can also keep doctors from prescribing the more expensive drugs of choice, forcing patients to take medications that are less effective or have worse side effects.

Before one patient could try Botox, her health insurance, Cigna, required her to try and fail at least two others. She tried tricyclic antidepressants, which made her groggy, and beta blockers, a class of drugs used for high blood pressure and heart problems. The next time she went in for her Botox treatment, her doctor suggested she try Aimovig.

Amgen and Novartis, the two manufacturers, were offering two free injections before she could access the drug through her health insurance, but she declined, not wanting to start a new treatment that she felt would likely be denied in a few months because of its expense (Potenza). According to a recent survey by the Doctor-Patient Rights project, "the health of nearly one in four patients treating a chronic illness may be in jeopardy by insurance providers who deny coverage for their treatments" (Worthy).

Burnout for Physicians

The loss of physician autonomy plays a huge role in feelings of hopelessness and frustration that many of us experience. And I believe that health care — intrusion of third parties into the practice of medicine — is to blame for much of the distress, unhappiness, and frustration we see among physicians and those aspiring to practice medicine. Instead of adding more programs about wellness and resiliency to the medical school curricula, let’s recognize the root causes of systemic burnout — those which exist across the entire profession of medicine today — and empower both students and physicians with the skills necessary to advocate for and bring about needed change (O'Connor).

Physicians Foundation found that in 2018, 46 percent of physicians surveyed would consider a career change. The survey also noted that 37.7 percent of physicians say that regulations and insurance requirements cause them dissatisfaction and take away from their intended purpose — to care for people (O'Connor).

Many doctors are fed up, often leaving the field: "Insurance companies dictating and questioning our orders for treatment of our patients, including but not limited to: prior authorizations for prescriptions, diagnostic tests, therapies — in short scientifically evidence-based medicine proven to help our patients — is being limited, impeded, or outright denied, all in the name of profit" (Choi).

Such interference in doctors' expertise as primary voices for their patients' treatment decisions has dire consequences for patients and their physicians trying to provide them with the most effective care.

Migraineurs have enough burdens to face enduring the disease, without obstacles and setbacks forced upon them by those who should be partners in their healthcare.

References

Ducharme, Jamie.  "A Year After Approval, Migraine Drugs Are Changing Lives. But Insurance Battles Are Creating a Whole New Headache" Time magazine https://time.com/5608386/cgrp-migraine-drugs-insurance. Accessed 21 November 2020.

 Worthy, Stacy. “Doctors, Not Insurance Companies, Should Make Medical Decisions.” Newsweek 8/17. https://www.newsweek.com/doctors-not-insurance-companies-should-take-medical-decisions-650872. Accessed 20 November 2020.

Potenza, Alessandra. "Why I had to wait two years to get Botox for my migraines” The Verge. https://www.theverge.com 2018 18 November 2020.

Choi, Augustine. MK "Medical education needs to stop burning out students — now." August 2019. Stat Newscom.

O'Connor, Elizabeth. "Are Insurance Companies Driving Doctors Out of the Profession?"  09/07/19. https://thehill.com/opinion/healthcare/460377-are-insurance-companies-driving-doctors-out-of-the-profession?