Migraine

We have United Healthcare Insurance through my husband's employer. UHC limits the number of triptans--any triptan--to 4 per month. My neurologist and I sent in letters of appeal two months ago, and today the response came from UHC saying they are denying the appeal because "we have set a quantity limit on its coverage." Well, duh, that's the reason I was appealing! I just want to scream! It's like they never even considered my doctor's letter of medical necessity (he asked for a minimum of 18 per month for me). I do plan to re-appeal. I can not take it to our state insurance board, as it is a self-funded Group Employee insurance plan and not subject to state insurance law. Can anyone help me out here? Does anyone have any solid advice other than appealing a second time? What in the world are they thinking (other than the obvious thing of saving money)? I have cried buckets of tears over this. It is very, very scary, to say the least. Thankfully I had "stockpiled" meds from last year when we had a very liberal plan, or else I would be in deep trouble right now.

Wow...I'm not crazy about triptans but limiting the coverage to 4 per month seems low even to me. It's like they're telling you that you'd better not have more than 2 attacks per month because they "said so, that's why"!

You can see if your pharmacist will sell them to you without billing your insurance company. It would be expensive as all get-out but I'm not aware that it's illegal. A person could give their prescriptions to a pharmacist and never mention that they have prescription coverage, and that would work, wouldn't it?

How is your preventative plan working? Right now, my worst triggers are uncontrollable ones--weather! Hurricane Ike is coming and we've still got evacuees in town from Gustav. Means I have to really stay on top of my other triggers. Doesn't always help but sometimes it does.

Far better to prevent attacks than have to medicate them, I always say.

I've been working with many preventatives (herbal and prescription) for over 8 years now. Depakote worked really well for me but I couldn't tolerate the side effects. Nothing else (so far) has helped. I have graduated to mix & match Rx's now. I don't like the triptans, either, but definitely need them as I average 8 migraines a month, and sometimes I need more than one triptan (I prefer Axert) to treat an attack. Sure, I can buy the triptans without using my insurance, but as a stay-at-home mom trying to make it on just one income we really can't afford that. And why should we, when we are paying the premiums for our insurance? I doubt they are limiting insulin for diabetics, and I know they don't limit our daughter's ashtma drugs....ooops....better not say that out loud.....I just don't get why they are picking on migraineurs.

Ride out those hurricanes! Weather is a trigger for me, too.

Ann,

Is your insurance through your husband's employer? If so, he needs to make an appointment and discuss this with someone in human resources. Sometimes, the limits are because of the level of coverage the employer has set, and they can do something to help.

Just a thought.

quote:

Originally posted by Ann B:
I've been working with many preventatives (herbal and prescription) for over 8 years now. Depakote worked really well for me but I couldn't tolerate the side effects. Nothing else (so far) has helped. I have graduated to mix & match Rx's now. I don't like the triptans, either, but definitely need them as I average 8 migraines a month, and sometimes I need more than one triptan (I prefer Axert) to treat an attack. Sure, I can buy the triptans without using my insurance, but as a stay-at-home mom trying to make it on just one income we really can't afford that. And why should we, when we are paying the premiums for our insurance? I doubt they are limiting insulin for diabetics, and I know they don't limit our daughter's ashtma drugs....ooops....better not say that out loud.....I just don't get why they are picking on migraineurs.

Ride out those hurricanes! Weather is a trigger for me, too.

Ann, you may also want to talk to this chronic illness advocate as well: Advocacy for Patients with Chronic Illness

She's often able to help those with chronic illness (like Migraine) in advocacy issues, and I don't think she charges (just asks for donations from those who are able).

Ann -

I have Oxford, which is in the "United Healthcare family of companies". A year ago they suddenly limited me to 4 Imitrex per month. Their justification was "most people don't need more than 4 per month." Initially I was getting the 4 per month covered and paying out of pocket for the other 5 pills in the pack - and with a $50(!!!) co-pay on the 4 pills that meant they were essentially paying for 2 pills!

I appealed and then they told me that with a letter from my doctor, they would cover 9 pills every 23 days. So I got another letter from my doctor and they started covering an entire pack. I share this just in case it makes a difference to point out to them that one of their divisions is treating it differently.

I would say to them just what you said to us - that they wouldn't limit insulin to a diabetic, inhalers to an asthmatic, or blood pressure medication. There are a bunch of articles on this site with info, study references, etc, you could include info from:

Migraine is a Progressive Brain Disease and

Migraines Cause Brain Damage to show them the dangers of untreated Migraines, and


Status Migrainous to show them that an untreated Migraine attack can require emergency treatment.

Maybe you can point out that without triptans, you'll need to go to the Emergency room and that will cost them considerably more (I don't have figures, but maybe you could find out).

Teri also had a story about an insurance issue she handled somewhere on the site (maybe someone else can find the link?) where she told the insurance representative that their company was practicing medicine without a license, and prescribing without seeing the patient, as they were setting up their "wisdom" as to what the patient needed in contravention to the doctor's orders.

In terms of making it a little more affordable, I also ask for samples every time I see my neurologist and every time I see my primary care physician, if each gives me 2 or 3, that adds about a month's worth for free every year.

Good luck Ann! So sorry you have to deal with this!

- Megs

Ann, I have United Healthcare through my husband's employer too. They are also self funded. I don't know if it helps much but I'm allowed 6 relpax (triptan) and 9 frova a month. I get both plus many other meds every month. There was a time when I was getting 9 relpax a month without any troubles but that was a long time ago so I don't know if they would let me now.

Have your husband call. The few times I've had a problem, he called them and if he didn't get anywhere, he called the person from his employer who handles benefits. That has usually solved things.

I hope you can get more than 4 a month. A letter from a doctor explaining why should have been enough. Insurance companies have gotten way too powerful!

Thanks to all of you who have responded. Yep, Teri and Hoopsky, my husband has finally agreed to get into the action with his employer. It seems to us that his employer bought the very lowest coverage available for their employees from UHC (our deductibles and out-of-pocket limits are horrendously high). Unfortunately, there is no insurance liason in our HR, and the top HR person at my husband's location isn't high enough in the company to do much about the problems. Frustration all around. Thanks for the link to the advocacy person, MaxJerz, I will check it out. And for all your helpful suggestions, Nutmegan. It looks like I have a lot of writing to do! I know I have to put up with it and just plow through this, but I really want to throw a tantrum right now and scream "It's not fair!" I'm sure you can all understand :-) Caution: more rant ahead: isn't this simple math? Even if it's true that the "average" migaineur uses 4 triptans a month (according to United Healthcare), doesn't simple math tell us that while some people might only need one or two, there are those out there that then need 6 or 7 (or more)? Really now. This seems so obvious to me. You're so right, Nutmegan. They are practicing medicine without a license to keep me from medicine that I need. I never thought of it that way before. Has anyone taken an insurance company to court under that pretense before? I honestly don't think I'm up to that, but would love to see it happen.

Edited by Community Manager: Remember to keep it family friendly!

Hi Ann B.

I'm sorry you are having a hard time with your insurance company. Everyone has given you good information.

What concerns me is the eight Migraines a month. After reading the article Yes, Migraines Can Cause Brain Damage it is more important then ever to reduce the frequency of our Migraines.

Is it time for a new doctor? Maybe taking this quiz will help. Is Your Doctor Right For You? Then you can take a look at our patient recommended specialists list HERE.

Good luck with the health insurance. Keep us posted, ok?

quote:

Has anyone taken an insurance company to court under that pretense before? I honestly don't think I'm up to that, but would love to see it happen.

I don't know - and taking anyone to court is a big undertaking. But in that letter Teri did (maybe it wasn't on this site, maybe I read about it in her book? Somebody help me out here?) I think she told them she would be posting on her blog an announcement of them practicing medicine without a license, or some such.

For me, the point is, we don't have to be "nice" about it. Of course it's wiser to be calm and polite with the people we have to deal with, but I think it's fine to say, "I'm afraid you leave me no option but to... publish what you're doing on line, or hand this over to an attorney," or ... fill in the blank.

This is the link Megs was talking about, I think:

Migraine, Medications, and Insurance Companies

Thanks again, all, for your replies. I truly do appreciate them as I try to wade through this. Things went from bad to worse this afternoon as a pharmacist from our mail-order pharmacy called and said that after reviewing my prescription, I could get 12 and only 12 Zomig for a 3 month supply, no ifs, ands or buts about it, because that's all my plan allows for. I informed her that countless reps had told me I could indeed get as many as my doctor prescribed as long as I was willing to pay for difference, and also directed her to our insurance company's policy on that, but she didn't want to hear it. I was once again reduced to tears when I received a call from another pharmacist who said she is a customer support pharmacist from our mail order company. I thought that was so strange; nobody from there had ever initiated a call to me before. Anyhow, she told me she is a migraneur and also on Zomig. She told me the first pharmacist was wrong, and that my plan does allow me to keep reordering my Zomig as long as I make a new copayment each time. Still fundamentally unfair, but at this point I'm just happy to know (maybe? of course the next person I talk to can have no idea and change the rules again) that I can get pills to treat the pain. And my husband found out that his company does indeed have an insurance liason. She needs all the documentation, so I am off to start that process. Thanks again to all.

Nancy--yes, I've worked with a number of doctors, including a neuro who specializes in headaches, a homeopath, an internist, my family doc, and now a new neurologist. That's in the past 8 years since I had a brain tumor removed (so I have some complicating issues). I'm not sure about the new neurologist. He is dead set against using more than two preventatives at a time (right now I am on Topamax and Verapamil). But I look at the rather long list that some of you are on and wonder if it won't take more....

Ann have you had any movement on this issue?

Cindy