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