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Migraine Disease and Medicare

by Danielle Kunkle, Guest Writer

A migraine is one of five types of headache disorders. There are several types of migraines, including common migraine, complicated migraine, and chronic migraine. According to the Migraine Research Foundation, females experience migraine attacks more than males. In fact, out of the four million people who suffer chronic migraines, 85% of them are women. If you have chronic migraine, you experience at least 15 days of migraine symptoms within a month.

Although the occurrence of migraine decreases after age 60, many seniors still experience disabling migraine. Certain treatments can prevent or lower the number of migraine attacks you experience each month. Medicare offers multiple covered solutions to prevent and treat migraine disease.

Botox treatment for chronic migraine

Botox is an FDA-approved treatment for chronic migraine. Actually, Botox is the only FDA-approved treatment for preventing chronic migraines, and it is covered by Medicare when used for migraine treatment. Medicare does not cover Botox for cosmetic reasons.

Medicare Part B covers Botox treatment for chronic migraines if the treatment is ordered and performed by a doctor who accepts Medicare. Medicare requires the doctor to document that the patient 1) has been diagnosed with chronic migraines; 2) has chronic migraine symptoms, and 3) has tried at least two other forms of treatment that have failed.

If the Botox treatment is approved by Medicare, then Part B will cover 80% of the cost after a $185 annual deductible. For example, if Botox costs $300, you’ll pay $185 to meet your deductible, plus 20% of the remaining cost in Part B coinsurance. At the next treatment, since your deductible is met, you would pay $60 in coinsurance for a $300 treatment.

However, if your doctor doesn’t accept Medicare assignment, you could be charged 115% of the Medicare-approved amount for the treatment. Medigap plans such as Part G covers these excess charges and your Part B coinsurance.

Prescription drug treatment for migraines

Medicare also covers prescription treatment for all types of migraines. Medicare Part D provides prescription coverage for Medicare beneficiaries. Although each Part D plan can cover different medications at different costs, the structure of the plans is the same.

Every Part D plan has four stages – the deductible, initial coverage, coverage gap (donut hole), and catastrophic coverage. The deductible can be as high as $435 in 2020 and may only be required for certain types of drugs.

After you have paid the deductible, you move into the initial coverage stage, where you pay either a copay or coinsurance for your medications. These costs are based on which tier the medication is listed as on your plan. For instance, you may have a $10 copay for tier-one drugs, but a 40% coinsurance for tier-four drugs.

Once you and your plan have paid a certain amount, you’ll move into the donut hole, where you will pay 25% of your drug costs. This coinsurance may be higher or lower than what you were paying in your initial coverage stage. Once you have reached the donut hole cap, you will move into the catastrophic coverage stage, where you will pay around 5% of your drug costs.

All Part D plans are required to cover at least two drugs from each therapeutic class. However, they usually offer more than two. People who suffer from migraines usually have several options for medications covered by their Part D plan. For example, according to GoodRX, 100% of Part D plans cover propranolol, topiramate, and amitriptyline, which can all treat and/or prevent migraines.

Part D Restrictions

Part D plans are allowed to have certain restrictions on the medications they cover. Allowed restrictions include quantity limits, prior authorization, and step therapy. Quantity limits mean that the plan will only cover a certain amount of that medication each month. This restriction usually applies to narcotic pain medications.

Prior authorization means the plan requires the doctor to document why the prescription is needed so the plan can confirm that the medication is being used correctly for a condition covered by Medicare. Step therapy means that there is a lower-cost alternative for that prescription, and the plan wants you to try that lower-cost drug first. If the lower-cost drug doesn’t work, then the plan may cover the higher cost drug instead.

Conclusion

As you can see, Medicare covers treatments commonly used for migraines. Medicare Part B also covers tests and lab work used to diagnose migraines when medically necessary. For example, if the doctor needs to rule out other conditions to diagnose you with migraines, Medicare will cover those diagnostic tests. From diagnosing migraines to treating them, Medicare is your health care partner.

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