My claim for
Nurtec
was denied.Now what?
We know how frustrating, scary, and confusing this can be, but you’ve come to the right place. First and foremost, it’s important to know that you can appeal. It’s your right!
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Learn more about Nurtec
What is Nurtec used to treat?
Nurtec (rimegepant) (also known asrimegepant) can help stop and prevent migraines. It's taken as a pill you take either when you need it to stop a migraine or scheduled every other day to prevent migraines. It works by helping mute pain signals in your head and neck that would otherwise be part of a migraine attack.
How can Nurtec help me?
<p class="font_8">Nurtec (rimegepant) is used to help people who have frequent migraines and for those whose migraines impact their ability to function. It can help stop a migraine after it starts, and can help keep them from starting in the first place.
As with any medication, results can vary. When it comes to stopping a migraine that has already started, Nurtec helps with both reducing pain and returning to normal life faster. When looking at keeping migraines from happening, people experience anywhere from a 30% to 75% reduction in migraine frequency.
In addition to reducing migraine frequency, there are several other goals to consider when starting Nurtec:
1. Reducing how painful migraines are when they happen
2. Reducing how often you need to use medications to stop a migraine
3. Improving your ability to function in your daily life and reducing how much migraines impact your daily life
4. Regaining a sense of control and management of your migraines
5. Improving your overall health-related quality of life
6. Reducing the amount of distress and mental strain caused by headaches, which is common when you don’t know and can’t control when your next migraine attack will happen</p>
What do doctors usually consider before trying Nurtec?
Migraine treatment usually starts with trying to control the pain of the headache. For more severe headaches that have an impact on your daily life, or happen more frequently, doctors will try treatments that aim to stop the headache quickly once it begins.
If these options aren’t working, and you have migraines at least four days a month without a major impact on your life, or at least two days a month with a serious impact on your life, your doctor will likely consider a preventative medication, like Nurtec, as a next step.
So the usual pattern is:
1. Pain management: using drugs like Tylenol or Ibuprofen to reduce the pain of the headaches
2. “Abortive” treatments: using drugs to “abort” or “stop” the migraine quickly when they start. The generic names for these end in “-triptan”, and include Amerge, Axert, Frova, Maxalt, Relpax, Imitrex, and Zomig
3. Preventive treatments: using different types of drugs to keep the migraines from happening in the first place. There are two levels to this:
1. First-line preventive treatments: The first medications tried are usually Depakote, Topamax, Neurontin, Elavil, Effexor, verapamil, or beta-blockers (drugs that end in “-olol”)
2. Second-line preventive treatments: If all the above fails to control or reduce migraines, doctors start to consider medications like Aimovig, Nurtec, and others (”CGRP inhibitors”)
What are the coverage criteria for Nurtec?
For Nurtec to be approved for preventing migraines, you need to have:At least 4 days with migraines per month for the past 3 months
And you cannot have:
1. Tension headache
2. Hemiplegic migraineIf this describes your symptoms, and you do not have one of the excluded conditions, you may be a good candidate for Nurtec approval. However, your treatment history matters. Often you will need to have tried other treatments before your insurance company will approve Nurtec. The exact requirements can vary depending on the insurance plan, but below are the general guidelines: 1. A trial of at least 2 different preventive medications for migraines, often for anywhere from 2 to 3 months.
1. Example medications include: Depakote and Depakote ER, Topamax, Neurontin, Elavil, Effexor, verapamil, or beta-blockers (drugs that end in “-olol”)
2. These medications did not work for you during that trial period
3. Some insurers will not count medications you got as samples from your doctor or from discount/coupons
2. A trial of a medication to treat or stop migraines
1. Example medications are all the drugs where the generic name ends in “Triptan”: Amerge, Axert, Frova, Maxalt, Relpax, Imitrex, Zomig
2. These medications did not work for you during that trial period, or you were not able to take them for some reason (they were “contraindicated.” If this is the case, make sure your doctor notes it in your records)
3. For some insurers, they will not count any medications you got from samples from your doctor or from discounts or coupons
3. Some insurers will also require that you have a trial of Botox for chronic migraine prevention. This can be for 6 months in some cases, and may require a separate prior authorization.
4. In most cases, you cannot be taking any other similar medication (e.g. Aimovig, Qulipta, Vyepti)If you meet the above criteria, you will usually get an initial authorization, which will be active for on average. To continue receiving insurance coverage for Nurtec it means:
What you can do to help your case?
Make sure your doctor is recording all different types of migraines that you suffer from. For instance, if you have migraines with aura and also have episodes without aura, make sure both are included in your records. Once you get a diagnosis of chronic migraine, however, that difference in coding becomes less important.
Track your migraines. Keep track of how often your headaches happen and their impact on your life (having to miss work or school, skip appointments, avoid driving, etc)
Track the drugs you’ve already tried. This improves your ability to say whether you can skip ahead in the process, especially if your doctor makes note of it.
Note if you have had headaches from your medications, or “medication overuse headaches”. Medications like Aimovig both help reduce headaches and do not cause an overuse headache, meaning they might be the best option for people with medication overuse headache.
Get help writing your appeal. These are complicated documents to write well. But we can take your details, cite the evidence, and improve your chance of turning that denial into an approval. We can help. Start your appeal today.
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References
Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153
Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153
Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153
Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153
Choose a denial
reason to appeal:
No Prior Authorization (PA)
Your doctor did not submit the paperwork required by the insurer to show that you have tried other medications first.
Initial approval ended
The initial approval of Aimovig is sometimes only for a specific amount of time (such a 3 month period).
Why It's common for
Nurtec
Some doctors and their staff do not know which insurance plans require Prior Authorization for which drugs.
How to appeal
Ask your doctor’s office to submit an initial Prior Authorization request to your insurance company. You can also try sending an appeal that details all the treatment options you and your doctor have already tried. That said, a doctor’s office might get a faster result.
Why It's common for
Nurtec
Insurers want to see that the treatment is working after an initial trial.
How to appeal
Ask your doctor’s office to submit a Prior Authorization renewal to your insurance company. You can also submit your own request, though your doctor’s office might get a faster result. You have to include information on how the treatment has improved your symptoms. This usually means you have fewer migraine days AND you have a "significant clinical benefit" according to your prescribing doctor (sometimes that benefit can be self-assessed).
Why It's common for
Nurtec
Insurers only want to pay for therapies that continue to work well and give you benefit.
How to appeal
Ask your doctor’s office to submit a Prior Authorization renewal to your insurance company. You can also submit your own request, though your doctor’s office might get a faster result. You have to include information on how the treatment has improved your symptoms. This usually means you have fewer migraine days AND you have a "significant clinical benefit" according to your prescribing doctor (sometimes that benefit can be self-assessed).
Why It's common for
Nurtec
Insurers sometimes
Do not know your symptoms enough to see how you qualify
Are not following their own rules
Are not following the rules of your state
How to appeal
Document that you are no longer taking that medication.
On a drug that is not allowed at the same time
Some policies do not allow you to be on certain combinations of medications at the same time.
Medical necessity
Your insurance company does not have the information needed to show you meet their criteria. Or, your insurance company knows your history and still thinks you do not meet their rules.
Why It's common for
Nurtec
5 Some doctors and their staff do not know which insurance plans require Prior Authorization for which medications.
How to appeal
Make sure your symptoms are clear: how severe, how often, and how they impact your life. Check them against the insurance company’s rules to make sure they’re applying their rules correctly. Check state law where you live to see if the rules are different for your area. Not sure where to start? See how we can create a personalized appeal for you in minutes.
Why It's common for
Nurtec
Some doctors and their staff do not know which insurance plans require Prior Authorization for which medications.
How to appeal
Ask your doctor’s office to submit an initial Prior Authorization request to your insurance company. You can also try sending an appeal that details all the treatment options you and your doctor have already tried. That said, a doctor’s office might get a faster result.