Insurance won’t give Prior Authorization
Prior to being married, I had state medicaid for insurance and was using a medication called Emgality for my migraines. When I got married and put on my husband insurance, they denied it, saying I do not have enough migraine days per month. The denial letter said I had not tried Ajovy (as well as the 4 listed below) so my doctor gave me a prescription for Ajovy.
Two appeals later, they're still denying the Ajovy.
The denial was based on our criteria for Ajovy Inj 225.1.5.
Per your health plan's criteria, this drug is covered if you meet the following:
Two of the following:
You have tried amitriptyline or venlafaxine for at least two months or cannot use the drugs.
You have tried divalproex sodium or topiramate for at least two months or cannot use the drugs.
You have tried one beta blocker drug (that is, atenolol, propranolol, nadolol, timolol. or metaprolol) for at least two months or cannot use the drugs.
You have tried candesarten for at least two months or cannot use the drugs.
Options 3 & 4 are intended for lowering blood pressure. This would be very dangerous for me, as I have naturally low blood pressure and a history of fainting. I've seen a cardiologist for it. This information was included in the latest appeal and it was still denied. I have asked for a copy of the headache specialist's appeal letters, so far I've only received the appeal that did not include my blood pressure.
From the way I am reading it, "cannot take the drugs" counts. So I have fulfilled two of the four options. I called the headache clinic, the medical assistant explained it as I still need to try Option 1 & 2. So it comes to a disagreement over how the letter is worded?
We get our insurance through my husband's employer. He's been discussing it with his HR department, who brought the corporate benefits team and Quantum Health in on it. My husband's manager had a similar issue and needed to get a lawyer involved.
submitted by /u/VeeRook
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