Health Plans’ Prescribing Restrictions Undercut Migraine Treatment

On top of debilitating pain and widespread stigma, patients with migraine now face another challenge.  If they want preventive treatment, they must first find a physician that their health plan will allow to prescribe it.

Known as CGRP inhibitors, preventive drugs for migraine are a welcome innovation.  They offer patients a coveted chance to reclaim their day-to-day lives. Yet insurers in Kansas, Pennsylvania and Florida say that health care providers cannot prescribe CGRP inhibitors unless they are neurologists.  Headache specialists. And members of the United Council for Neurologic Subspecialties – or in consultation with one.  

That’s only about three percent of neurologists nationwide.

Granted, the drugs are costly.  But insurers’ requirement creates a serious access barrier for patients – for several reasons.

  • The numbers don’t make sense.  The United States has fewer than 500 headache specialists in practice, but it has 38 million people living with migraine.  Even if these physicians and patients were evenly distributed across the country, physicians would be hard pressed to handle the patient load.  

But patients and physicians aren’t evenly distributed.  Just consider Kansas. The state has zero United Council for Neurologic Subspecialties headache specialists in practice. Yet one of the state’s largest health insurers dictates that migraine patients living in Kansas must see one if they need a CGRP inhibitor.  

That leaves migraine patients with a tough choice – travel out of state to find a doctor who can help them, or simply forego treatment that could be life changing.

  • The requirement will worsen existing treatment challenges.  Migraine patients don’t know on any given day how they will feel when they wake up.  Adding undue burdens such as long drives, out-of-state travel or wait periods can prolong patients’ pain.

Meanwhile, by bestowing only a small fraction of neurologists with the ability to prescribe CGRP inhibitors, insurers basically guarantee that these neurologists will face an unmanageable patient load.  A majority of neurologists already face burnout.  Increasing that rate does not bode well for either physicians or their patients.

  • The requirement ignores a basic reality.  Some patients with migraine or other headache disorders receive regular treatment from a physician who is not a headache specialist – perhaps a neurologist, a general practitioner, a nurse practitioner or another clinician who is their primary care provider.  The course of treatment has given these practitioners a thorough knowledge of these patients, their symptoms, their history and their experience with side effects. These patients, in turn, trust their provider and look to him or her for guidance in treating their migraine.

Insurers’ restrictions on prescribing ask these patients to leave the health care provider they trust and fight travel hassles and long wait times to seek treatment from a physician they’ve never met.

The issue of prescribing restrictions has sparked concern among patient advocates.  The Headache & Migraine Policy Forum recently submitted a letter to Blue Cross Blue Shield of Kansas encouraging the insurer to “reevaluate its coverage policy to allow all providers – including primary care physicians who as a practical matter fill the specialist vacuum and treat migraine patients in Kansas – to prescribe these life-changing medications.” The state’s insurance commissioner is conducting an inquiry into the matter.

Meanwhile, patients in Kansas and elsewhere wade through red tape – or simply wait in pain – while the preventive treatment they’ve longed for remains just out of reach.


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