How to Get Prior Authorizations for Migraine Medications Approved
Celebrities such as Kristin Chenoweth, Whoopi Goldberg, Hugh Jackman, Serena Williams, Ben Affleck, Virginia Madsen, Lady Gaga, Lisa Kudrow, Jennifer Morrison, James Cromwell, Khloe Kardashian Whitney Cummings, and Terrell Davis are all living with migraine disease (Glaser, 2023). Many have contributed to raising awareness for the migraine community by bringing national attention to migraine, a neurological condition that affects almost 40 million Americans.
Migraine is a neuroinflammatory disorder that tends to occur across a patient’s lifespan. Patients experience episodic exacerbations and age-dependent changes in clinical presentation and prevalence. The understanding of migraine shifted in the late 1990s. Modern understanding of migraine pathophysiology radically changed the migraine treatment paradigm, ushering in a new era of migraine-specific therapies such as 5-hydroxytryptamine 1F (5-HT1F) receptor agonists followed by calcitonin gene-related peptide (CGRP) receptor antagonists (Gibb & Al-Arabi, 2023).
Many patients, inspired by celebrities endorsing new migraine medications on TV, visit their primary care provider or neurologist with a list of medications they want to try. As a headache provider, I have seen terrific results with countless patients who started using the migraine-specific medications and finally got their lives back, stolen by migraine years ago, in some cases as long as 30-40 years ago. As thrilled as I have been by a high success rate of the CGRP inhibitors in the last 3-4 years, I also face countless obstacles, both foreseen and unforeseen, when I complete prior authorizations (PA) to get these medications approved or renewed for my patients. I’ve been working closely with several specialty pharmacists specializing in headache medications and would like to share the helpful tips I have learned.
Insurance Companies follow the American Headache Society (AHS) Consensus Statement
The insurance companies follow the “American Headache Society consensus statement: Update on integrating new migraine treatments into clinical practice” by Ailani, J., Burch, R. C., Robbins, M. S., & Board of Directors of the American Headache Society. (2021).¹
Please, see Appendix 1 Optimizing drug selection to help guide you.
History of Present Illness (HPI) Documentation
Certain information needs to be documented in the chart under HPI in order for all questions on a PA to be answered. Otherwise, PA will be returned as incomplete or will be denied. Quite often, office or pharmacy staff will skip these questions if they cannot find the answers in the chart that often results in PA denials.
The exact number of migraine headache days per month needs to be documented. The examples of the questions on PAs could include the following:
- How many migraine headache days per month does the patient have?
- How many headache days did the patient have PRIOR to starting the treatment with the requested agent? It is important to document if you gave your patient samples, they saw significant improvement, and you documented the improvement in their chart.
- Does the patient have more than 4 migraine headache days a month?
- Does the patient have more than 8 migraine headache days a month?
- Does the patient have more than 15 migraine headache days a month?
- For patients with 15 or more migraine headache days per month some insurance plans will only cover medications approved for chronic migraine such as atogepant (Quilipta) or onabotulinumtoxinA (Botox).
- Some insurances will not cover CGRP monoclonal antibodies if the patient has more than 15 headache days a month. They often state they do not cover “experimental treatments” such as galcanezumab (Emgality) for chronic migraine.
Choose Your Diagnosis Correctly
When your staff completes a PA for a migraine-specific medication in CoverMyMeds, they need to answer the question: “Does the patient have one of the following conditions?
- Episodic migraine with aura
- Episodic migraine without aura
- Chronic migraine with aura
- Chronic migraine without aura
If you choose a very specific diagnosis such as “ocular migraine” or “persistent migraine aura without cerebral infarction,” the person who completes a PA may not see that diagnosis in the drop-down and may answer “no” to the question, which will result in denial.
If You Order A Migraine Preventive Medication, Medication Overuse Headache Needs to be Ruled Out
Many insurance plans will ask you a question if Medication Overuse Headache has been ruled out, especially if you prescribe CGRP monoclonal antibodies.
You Will Need to Complete PAs Every 6 to 12 Months Depending on the Insurance Plan and Provide Supporting Visit Notes
- Some of my patients cancel their 6-month appointments as their migraine attacks become very well controlled but a refill request is still able to be approved at this point.
- When the pharmacy sends another refill request at the next 6 month interval, the coverage gets denied if there are no visit notes available for the last 12 months.
- Emphasize to your patients that keeping appointments is key to getting coverage for high-cost medications.
Migraine Pharmacological Treatments are Divided Into Acute and Preventive Treatments
- With acute treatments, a trial of treatment with 2 triptans is required by almost all insurance companies before coverage of a gepant such as Rimegepant (Nurtec ODT) or Ubrogepant (Ubrelvy) or a ditan like lasmiditan (Reyvow). Very few plans require one trial of a triptan.
- Document the trial of 2 of the following triptans in HPI:
- Almotriptan (Axert)
- Eletriptan (Relpax)
- Frovatriptan (Frova)
- Naratriptan (Amerge)
- Rizatriptan (Maxalt)
- Sumatriptan (Imitrex, Onzetra Xsail, Sumavel DosePro)
- Zolmitriptan (Zomig)
- Sumatriptan/naproxen sodium (Treximet)
- If the patient had intolerable side effects or allergic reactions, they need to be documented in HPI and/or under allergies.
- Although sumatriptan oral tablets are covered by all plans without a PA, some triptans such as almotriptan (Axert), frovatriptan (Frova), and sumatriptan nasal spray or subcutaneous injection may still require a PA.
- Some insurance plans will require a trial of two triptans prior to approving a high cost NSAIDS such as Diclofenac (Cambia) or Celecoxib (Elyxyb).
- Some plans will only cover a certain number of doses of a medication per month
- Certain plans will cover 8 or 10 doses of ubrogepant (Ubrelvy) per month while other plans will cover 16 doses.
- If the prescription for 16 doses is denied, submit another for 10 or 8.
- Some plans will only cover 8 doses of rimegepant (Nurtec) but most will cover 16.
- When prescribing rimegepant (Nurtec), keep in mind that although the plan may cover 16 doses a month, the coverage requirements for acute indication are different from the coverage for the preventive indication. Make sure the patient meets the eligibility criteria.
View Appendix 2 Acute Treatments to help guide you.
The American Headache Society recommends offering preventive treatment if a patient reports more than 6 headache days per month. Visit Appendix 3 Table 4.
- All insurance companies will ask about the past preventive treatments tried. Although the required past treatments vary by the insurance plan, all insurances want to know if the patient tried at least two of the following medications and for how long. The required treatment minimum is 8-12 weeks.
- amitriptyline (Elavil)
- beta blockers (propranolol (Inderal), timolol)
- candesartan (Atacand)
- divalproex sodium (Depakote)
- venlafaxine (Effexor)
- topiramate (Topamax)
If the patient had intolerable side effects or allergic reactions, they need to be documented in HPI and/or under allergies.
Also, as of 2023 some insurance plans will only cover one medication from the CGRP class of drugs. For example, if your patient is on atogepant (Qulipta) for prevention and ubrogepant (Ubrelvy) for acute treatment, both medications will not be covered anymore. You will need to discuss with your patient which one they want to continue.
View Appendix 3 Medications with evidence of efficacy in migraine prevention and Appendix 4 to help guide you.
Galcanezumab (Emgality) for cluster headache
When you prescribe galcanezumab (Emgality) for cluster patients, especially for newly diagnosed patients, make sure an adequate trial of verapamil has been initiated or completed.
Renewal of Existing Prescriptions When Your Patient Changes Insurance Plans
If your patient changes insurance plans, complete a new HPI that includes all the information mentioned above for a new PA.
- Keep in mind if the patient now has only 2-3 migraine attacks per month while taking rimegepant (Nurtec OTD) every other day for prevention x 2 years, the prescription with the new plan will likely be denied as the coverage with most plans starts only if the patient has more than 6-8 migraine days a month.
- Be sure to document how many migraine attacks the patient had prior to starting rimegepant (Nurtec ODT) and how many they currently have.
Patient Assistance is Available for Qualifying Patients
There are several programs that can provide high-cost migraine medications for qualifying patients at no cost. Visit needymeds.org. Patients will need to complete all the required paperwork including their social security number and annual income. You will need to sign the provider’s statement, which is about 1 or 2 pages. The paperwork needs to be renewed every 12 months.
Many new medicines and devices have been approved over the past few years for the treatment of headache diseases. Pharmaceutical companies and device manufacturers are currently offering financial assistance programs to help cover costs and get these new treatments into the hands of patients. The details for each program varies. To help you navigate, CHAMP created Financial Assistance Guides that provide easy-to-understand information, whether you have private or public insurance or are uninsured Migraine Financial Assistance Guides (headachemigraine.org)
Some manufacturers offer Patient Assistance Programs (PAPs) to help patients needing financial assistance to purchase necessary medications and devices. Migraine treatment is provided at no cost or at a very low cost for qualifying individuals. Patient Assistance Programs | National Headache Foundation (headaches.org)
Completing PAs for Migraine-Specific Medication is Time Consuming but Necessary
Be aware that the cost of healthcare services for a household with a person living with migraine is 70% higher than a family not affected by migraine (Migraine Research Foundation, 2021). The combination of healthcare costs and prescription drugs in correlation with productivity losses within the patient’s workplace accounts for $36 billion in the US alone. On average, a person with migraine loses 9 work days annually due to migraine (Bonafede et. al, 2018).
Hopefully, this information is helpful in decreasing your administrative workload as well as the disease burden of your patients, both medically and financially.
- Ailani, J., Burch, R. C., Robbins, M. S., & Board of Directors of the American Headache
Society. (2021). The American Headache Society consensus statement: Update on integrating new migraine treatments into clinical practice. Headache, 10.1111/head.14153. https://doi.org/10.1111/head.14153
- Bonafede, M., Sapra, S., Shah, N., Tepper, S., Cappell, K., & Desai, P. (2018). Direct and indirect healthcare resource utilization and costs among migraine patients in the United States. Headache, 58(5), 700–714. https://doi.org/10.1111/head.13275
- Dorfman, S. (2020, Sept 15). Stars put a spotlight on migraine treatment options. The Palm Beach Post. https://www.palmbeachpost.com/story/lifestyle/2020/09/15/celebs-share-their-migraine-experiences-including-treatment-options/3464562001/
- Gibb, Vera & Al-Arabi, Safa’a. (2023, June 13). Clinical Advisor. A Case of Severe Monthly Headaches in Teacher: Workup and Treatment. https://www.clinicaladvisor.com/home/topics/neurology-information-center/case-severe-monthly-headaches-migraine-workup-treatment/
- Glaser, A. (2023, Jan 4). Migraine in the Limelight: 25 Top Stars Who Have Migraine. MigraineAgain.https://www.migraineagain.com/top-stars-who-get-migraines/
- Migraine Research Foundation (2021). Migraine facts. https://migraineresearchfoundation.org/about-migraine/migraine-facts/
- Taylor, N. P. (2023, Jun 14). Pfizer makes Lady Gaga the star of Nurtec ODT migraine push. https://www.fiercepharma.com/marketing/pfizer-makes-lady-gaga-star-nurtec-odt-migraine-push#:~:text=After%20working%20with%20Khloe%20Kardashian,new%20face%20of%20Nurtec%20ODT)
- Patient Assistance Programs: https://headaches.org/resources/patient-assistance-programs
Optimizing drug selection
The optimal selection of preventive treatment is case-dependent, and decisions about the use of specific medications and nonpharmacologic approaches must account for a range of factors
All tables were copied using Snipping Tool from https://doi.org/10.1111/head.14153
Ailani, J., Burch, R. C., Robbins, M. S., & Board of Directors of the American Headache Society. (2021). The American Headache Society consensus statement: Update on integrating new migraine treatments into clinical practice. Headache, 10.1111/head.14153.
Vera Gibb, DNP, APRN, FNP-C, AQH, CCTP is a family nurse practitioner and an Assistant Professor, Graduate Studies Department, School of Nursing of The University of Texas Medical Branch (UTMB) at Galveston. She holds additional certifications in headache medicine and clinical trauma. She graduated from the UTMB in April 2022 with her DNP. Her doctorate quality improvement project was focused on migraine preventive management in primary care. Her article titled “Managing Migraine in Primary Care: 5 Things to know” was published by Medscape as a part of Editorial Collaboration with The American Headache Society the same month. Vera Gibb serves on the Advisory Board of The First Contact – Headache in Primary Care Program of the American Headache Society and is a Co-Chair of its APP education Task Force. She also serves on the Board of Directors of Coalition for Headache and Migraine Patients (CHAMP) and an active member of The National Headache Foundation and ClusterBusters. Vera Gibb was a participant in 2021, 2022, and 2023 Headache on the Hill (HOH), annual advocacy event in Washington DC, organized by the Alliance for Headache Disorders Advocacy (AHDA).