The past few years have brought major progress in how we prevent and manage migraine. CGRP-targeting medications like Aimovig, Emgality, Vyepti, Nurtec ODT, and Qulipta represent a shift in both the science and strategy of treating this condition.

They're often better tolerated and more effective than older medications, and they allow for more personalized care, whether that means a daily pill, a monthly injection, or a quarterly infusion.

But while the science has advanced, insurance coverage hasn’t kept up. Patients are still being denied access to these medications due to outdated policies, arbitrary formulary changes, and one-size-fits-all coverage rules. At Claimable, we’re working with patients, providers, and advocacy partners to challenge these barriers—and win.

If you’re facing a denied claim for a migraine medication, read on to understand the tactics insurance companies take to limit access to these treatments – and what you can do to get covered.

Understanding the migraine treatment landscape

As a migraine sufferer, I know that migraines are more than a bad headache. It’s a disabling neurological disease that affects over 40 million people in the U.S. and is a leading cause of missed work and reduced quality of life.

CGRP (calcitonin gene-related peptide) medications have transformed our ability to treat and prevent migraine. Unlike older medications developed for other conditions (like epilepsy or depression), CGRP drugs are designed specifically for migraine. They target the biological mechanisms believed to drive attacks, offering relief with fewer side effects.

Why migraine coverage is so challenging

Even though these medications are FDA-approved and supported by professional guidelines, insurance plans often:

• Require you to fail older, less effective drugs first
• Only cover one CGRP drug despite clinical differences
• Force patients to switch medications mid-year due to rebate deals
• Approve treatment only temporarily, requiring re-authorization every few months
• Use vague or bureaucratic reasons to deny access altogether

This system doesn’t reflect the complexity of migraine or the individual needs of patients. It reflects cost-saving tactics that delay care.

Common migraine insurance denial reasons – and how we fight them

Step Therapy Requirements

What it is: Insurance insists you try and fail older medications (like triptans, topiramate or amitriptyline) before approving CGRP drugs.

Why it’s wrong: These older medications often come with tough side effects and weren’t designed for migraine. The American Headache Society supports CGRP drugs as a first-line option.

How we fight it: We submit detailed appeals outlining your treatment history, side effects from older meds, and professional guidelines that justify bypassing step therapy.

Formulary exclusions

What it is: Only one CGRP medication is covered. All others are denied.

Why it’s wrong: CGRP drugs aren’t interchangeable. A daily pill may work better for one person than a monthly injection. Side effects and effectiveness vary.

How we fight it: We explain the medical rationale for your chosen medication, using provider notes and evidence that shows why it’s not just a preference—it’s a necessity.

Mid-Year medication switching

What it is: Your plan changes coverage mid-year due to PBM rebate deals, forcing you to switch medications from a medication you’re stable on to what they prefer.

Why it’s wrong: Migraine treatment relies on consistency. Switching meds can cause rebound attacks and destabilize your care.

How we fight it: We focus on treatment stability and cite ERISA protections (if applicable) to challenge the fairness of mid-year changes.

Short-term or conditional approvals

What it is: You get approved for 30 or 60 days at a time, with constant re-authorization requirements.

Why it’s wrong: Migraine is chronic. Short-term approvals create anxiety, disrupt care, and burden providers.

How we fight it: We argue for long-term approval based on your condition and medication response, using both legal framing and clinical support.

"Not medically necessary" determinations

What it is: Your insurer denies a medication without a clear reason, claiming it’s not necessary.

Why it’s wrong: This ignores your provider’s judgment and contradicts clinical guidelines.

How we fight it: We present peer-reviewed studies, your provider’s rationale, and documentation showing how the treatment improves your quality of life.

Administrative or documentation barriers

What it is: Missing forms, technicalities, or unclear instructions result in denials.

Why it’s wrong: The insurer is making medical decisions by burying you in paperwork. Most people give up and concede to insurance demands. It’s generally understood that patients who accept non-medical switches have adverse side effects and poorer outcomes. 

How we fight it: We ensure everything is submitted cleanly and correctly, with language that anticipates common administrative objections.

How Claimable builds strong migraine appeals

As a patient, you have the right to challenge these denied claims. Insurers are required to comply with state and federal laws – which often require their denial rationale to be based on medical necessity, FDA standards, and other clinical, legal, and policy standards.

That means a strong appeal should include clinical evidence, legal standards, and policy compliance to hold insurance accountable to deliver your care and coverage. At Claimable, we use a multi-layered approach:

• Personal narrative: We capture your history, prior treatments, and how migraine affects your life. In particular this could be how you’re not able to enjoy your hobbies or do basic things like drive safely at night. We hear of patients becoming socially isolated. 
• Clinical evidence: We include the latest guidelines, studies, and medication-specific data. This includes the guidance from the American Headache Society, and other peer-reviewed studies and randomized controlled trials proving these medications are right for you. 
• Legal leverage: We reference plan terms, medical necessity requirements, and ERISA protections. This helps reinforce your rights to have a full and fair review of your care. An insurance doctor who has never met you shouldn’t get to make the call. 
• Collaborative advocacy: Your primary care doctor or neurologist can refer you for an appeal if they have a denial, or you can simply add their letter of medical necessity to your appeal to increase its strength.

Why this work matters – unlocking migraine coverage

The medications now available can change lives. But they only work if you can access and stay on them. No one should be forced to suffer just because their insurer hasn’t updated its playbook.

At Claimable, we don’t just file paperwork. We build appeals that reflect who you are, what you’ve been through, and why your treatment plan matters. If your migraine medication has been denied, disrupted, or downgraded, we’ll help you fight back—with precision, evidence, and persistence. Your journey matters to us.

Facing an insurance denial for Aimovig, Emgality, Nurtec or other migraine medication?

We’re here to help. Let’s make the system work for you—not against you.

Get started on your migraine appeal today.

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The first responses to Zepbound appeals for the CVS Caremark forced switch have started to come in. Claimable COO Alicia Graham breaks down what's in these new denial letters, and what that means next.

If you've gotten one of these letters, know that we're going to keep fighting it. We don't believe this rationale is based on medical necessity, nor that it will hold up to a secondary review. We're actively escalating these appeals, because we believe that you will win.

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This thing is getting more ridiculous by the day. As we start to see responses come back to CVS Caremark, I wanted to share what we've been seeing – because frankly, a lot of what they’ve said so far is vague, misleading and even straight up false. I don't believe these denials are in compliance with the plan policy, applicable laws, or clinical standards of care at all, and we're going to break down why that Is.

This is my take on exactly what’s in these denial letters, what it actually means, and what you can do if you got one. I know how confusing this is, and I hope this can help anyone navigating it.

The one size fits all “coverage request was not approved” denial letter

First of all, this is the language we’re seeing in almost all of these letters – just copy-pasted for everyone. By law, each appeal needs to be reviewed by a qualified human performing a full and fair review of specific case facts… so straight off the bat, it doesn’t look like they’re doing that.

“Your appeal for Zepbound has been determined as not medically necessary”

They say that current medical literature doesn’t support the use of Zepbound over the available formulary alternatives. Except it does (here's the head-to-head study we’ve been including in our appeals). They conveniently don’t include the studies they use to make their decision, which they’re supposed to do… so we have no idea why they ignored it and what they are using instead.

Plus, they’re saying Zepbound isn’t medically necessary, but Wegovy and Mounjaro are?! I don’t understand how that argument could ever stand up in a court. Wegovy is indicated for the same treatment with same coverage criteria, and Mounjaro... isn’t even indicated for weight loss.

“The primary covered drug for your plan is Wegovy”

“If the patient is unable to take the primary covered drug, chart notes must be submitted to CVS Health”. What they’re saying here is if you fail Wegovy, you could get back on Zepbound. This is step therapy, but in lots of states there are laws against this. If you live in New York, for example, they cannot require you to have previously failed Wegovy – but we’re seeing them do it anyway.

If you live in New York and got this, you should definitely fight it.

“The secondary covered drug for your plan is a tirzepatide product [Brand Mounjaro]”

This is a curveball – not what we expected to see. Yes, Mounjaro is a tirzepatide like Zepbound, but per the FDA it is only approved for type 2 diabetes.

If you and your doctor agree on you taking Mounjaro off-label, great! That’s completely up to you and what’s best for your care. But for your insurer to try to force you onto an off-label indication? Unethical, clinically absurd, and probably illegal.

But even more importantly this smells like a trap to me.

The trap: “Formulary alternatives may still require a clinical prior authorization”

They’re saying that Mounjaro may still require a PA. We’ve seen this before, so I want patients and providers to clearly understand the risk of going down this path.

The PA form states you do not qualify for Mounjaro unless you have type 2 diabetes, so the minute they ask for a PA your Mounjaro coverage will be gone. Even if they approve you without a PA today, at any time they can come back ask for it which will kick you off.

This has happened to several patients we’ve worked with who took Mounjaro for months and then were told they don’t qualify. They can force you off at any time because the criteria for Mounjaro is different.

The trap within the trap: The 180 day appeal window

I think a big part of them trying to lure you into doing Wegovy or Mounjaro is that by law, you only have 180 days to appeal your Zepbound denial. Hypothetically they could cover Mounjaro for those 180 days, and then on day 181 when that window expires and you’ve lost your right to fight for Zepbound, revoke your approval for Mounjaro – leaving you with nothing.

Even if you want to try Wegovy or Mounjaro, I would keep going on your Zepbound appeal at the same time. If you win a Zepbound appeal, they can’t just take it away.

Robocalls, app messages, and other nonsense

Legally, they have to send you a formal letter with details, full appeal rights, and more. But instead, they’re sending these mini-messages ahead of time and telling you to wait for the letter.

Why? Because not having all the info makes your response weaker and slows things down. Make sure you request your full claim file, formal denial letter, drug policy and all other decision documents. You’re legally entitled to them.

The bottom line: You don’t have to let them win

The TLDR; these denials don’t pass my smell test for compliance with the plan policy, applicable laws, or clinical standards of care. I don’t think these will hold up in external review, courts, or with regulators. So I say keep fighting.

If you got one of these, first request all the documents. Then, escalate it. In your denial letter there will be a number/address for the external reviewer to send it to. **You have the right for an external review and I think that if you do you will win.

At my company this is exactly what we’re doing. We’re creating secondary appeals that address every single piece of BS in these letters and escalating them to reviewers and regulators. Because PBMs and insurers are watching this – and the last thing I want is to show them that pulling stuff like this is ok. It’s not, and we’re going to fight it. And win.

– Alicia

PS – if you only have the “a change is coming on July 1” letter

I’ve seen a lot of people try to appeal using these letters – this will not work. This letter is not a denial of coverage for Zepbound. All this tells you that they will deny it if coverage is requested after July 1, but you can’t appeal based on this.

If you’ve only gotten this letter and want to try to stay on Zepbound, you need to get denied first. That means:

1. Your provider needs to submit a new prior authorization request for Zepbound (form here)
   1. It’s best to do this with a LOMN attached (template here, Lilly has one also)
2. You wait until that prior authorization gets denied
3. Then you can appeal

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If you’re one of the many patients impacted by the forced switch from Zepbound to Wegovy, you’ve probably received a confusing series of letters and messages – some from CVS Caremark, some from your doctor, and maybe even some from your pharmacy. Understanding what each document means is key to getting back on the path to coverage.

This article breaks down the three critical documents you’ve likely received through the process. We’ll show you what they are, what they mean, and – most importantly – how to use them to get covered again.

👉 If you haven’t already, check out our full guide to fighting the Zepbound switch here.

Document 1: The Formulary Change Notice Letter

What it is:

A notification of an upcoming change to your coverage. This letter tells you that soon, a change to formulary or drug policy will remove Zepbound and prefer Wegovy. It lays out steps to prepare, such as when to file a new prior authorization (for most people, after July 1st) and how to switch your prescription.

Why you get it:

Health insurers and pharmacy benefit managers, like CVS Caremark, must provide 60 days’ advance notice to plan participants before any mid-year formulary change that removes a drug from coverage or limits its availability (e.g. adds step therapy, prior authorization, or tiering).

How to read it:

The truth? There’s not a lot in here. These letters often use vague language like “no longer be covered” and “you’ll need to pay the full cost”, but don’t provide specifics. That’s because, importantly, this is not a denial, which is required to provide you much more detail. 

Key takeaway:

This letter alone does not mean that your Zepbound prescription has been denied, or trigger your right to appeal. It’s a heads-up, not a final decision.

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Document 2: Your Doctor’s New Prior Authorization Form

What it is:

A prior authorization is a form your doctor submits ahead of prescribing something, so the insurer can sign off on your treatment before it gets prescribed. With the Caremark switch, even if you had a prior authorization (PA) approved for Zepbound, your doctor must submit a new one after July 1. This is the PA form they must submit, and we also recommend they draft a letter of medical necessity.

Why it’s necessary:

Because Caremark’s formulary changed, all existing PA approvals under the old formulary are essentially wiped out. Your provider needs to justify, again, that the treatment is medically necessary and follows standard guidelines. If this feels like a huge waste of time, providers agree: PA has been proven to delay care and harm patients, and it’s costly for providers to complete.

How to use it:

Ask your doctor if a new PA has been submitted. This is your official request for your insurance to cover Zepbound, and it needs to be on record after July 1 for the appeals process to work. For best results, have them include a letter of medical necessity (you’ll also want this ready for your appeal). A little appreciation goes a long way.

Key takeaway:

An official denial won’t come until a new PA is submitted. This form restarts the process.

Document 3: The Denial Letter (Now You Can Appeal)

What it is:

This is the official decision from your insurer rejecting the PA request for Zepbound. It typically arrives by mail or through your health plan portal.

Why you get it:

Insurers and PBMs (like CVS Caremark) are legally required to ensure you understand the reason for a coverage denial and have a meaningful opportunity to appeal. When denial language is vague, incomplete, or misleading, it undermines this legal purpose and obstructs fair access to care – and if that happens, we can help you fight it.

How to read it:

Look for the specific denial rationale and appeal instructions. You might see language like “the primary covered drug for your plan is Wegovy” or “another option for you is a tirzepatide product.” 

This language is misleading: You always have the right to request a formulary exception when no equivalent alternative exists. Zepbound is the only FDA-approved tirzepatide for obesity and sleep apnea, and has also been proven to be more effective, with fewer side effects, than Wegovy. Thus, it is the only tirzepatide product that should be covered by your plan.

What we think? This gives you a strong case to stay on Zepbound in your appeal.

Key takeaway:

This denial is what makes you eligible to file an appeal. If you haven’t gotten this yet, first make sure the PA has been submitted. If you appeal before you get this denial, it may be rejected or ignored – but don’t worry if this happens. You can resubmit.

Putting It All Together

A successful Zepbound appeal means getting the documents right:

1. The 60-day notice tells you this is coming, but isn’t a denial.

2. Your doctor’s new PA starts the process under the new rules.

3. Your denial letter gives you the right to appeal.

👉 If you’ve received your denial letter and are ready to appeal, Claimable can help you fight back in minutes. Get started today.

Need Help?

Still confused? You’re not alone. These documents weren’t designed for patients. That’s why Claimable exists – to help you translate legal jargon into action. Reach out at support@getclaimable.com.