M igraine and headache sufferers go through a lot — piercing head pain , nausea , visual auras and the lifestyle upheaval that accompanies their condition . But if there ’ s one thing that rivals the sheer discomfort of a migraine or headache , it ’ s figuring out the insurance issues surrounding the condition ’ s care and treatment . Understanding the most effective therapies , haggling over which costs are covered by insurance providers and putting a figure to the inevitable out-ofpocket expenses can all feel like a shell game , says Bray Patrick-Lake , a migraine sufferer and patient representative for the Food and Drug Administration ( FDA ).
“ You see a migraine specialist , you pay for the appointment , you start the therapy and 30 days later you get a letter [ from the insurance company ] saying , ‘ We won ’ t pay for this medication so you need to switch to this cheaper drug ,’” Patrick-Lake says . “ It ’ s very frustrating .”
That ’ s why it ’ s essential to get a handle on the process . Here are four recommendations gleaned from physicians , health insurance insiders and patient advocates to help remove potential roadblocks to care and put you in control of your life .
If you need help paying for prescription drugs , try these NHFapproved patient assistance programs : www . headaches . org / education / Tools _ for _ Sufferers / Patient _ Assistance _ Programs- Sponsored
1 . Love the fine print
When it comes to insurance coverage , the cliché says it all : The devil is in the details . Most physicians and benefit industry reps agree that patients need to understand even the tiniest minutiae of their coverage .
“ Benefit or plan documents often get put into the kitchen drawer and never looked at or read ,” says John Whitney , MD , an internal medicine and pulmonary specialist who is also manager and medical director for medical policy with insurer WellPoint . “ One of the first things you can do is find them and read them .”
Unfortunately , some insurance plan documentation is so thick and laden with industry lingo that even the symbologist from the Da Vinci Code wouldn ’ t be able to tell whether , for instance , Imitrex falls under the coverage umbrella .
If migraine or headache sufferers don ’ t understand something about their benefit plan coverage , they should direct specific questions to their insurance companies , says Alan B . Rosenberg , MD , a physician and National Headache Foundation board member who has also served as an executive for a number of health benefit companies .
“ Benefit plan documents are sometimes difficult for individuals to understand ,” Dr . Rosenberg says . “ But headache patients can always call their benefit plan customer service number , and most large benefit companies have online query processes . Electronically submitted questions , given that they are written , provide a response that is clearly documented for the beneficiary .”
The takeaway from your research should be an encyclopedic knowledge of exactly what your plan covers — the specialists and physicians that are in-network , any copay requirements , the cost of generic versus name-brand prescriptions , the kinds of treatments classified as medically necessary , etc .
Moreover , Dr . Rosenberg says patients filing claims should understand which benefit they are trying to access . This is particularly important as it relates to pharmaceutical or medical benefits , as these may be directed to different places . For example , retail or mail-order pharmacy benefits are generally covered through pharmaceutical benefits . Physician office appointments , emergency room visits , hospital procedures , physical therapy and diagnostic imaging
36 HEAD WISE | Volume 1 , Issue 3 • 2011