What is covered by Medicare if you get migraines? Does Medicare cover migraines? It might cover Botox, Part A and B cover some prescription medications, but if take your meds at home you’ll need Part D coverage through either the stand-alone or advantage drug plan.
Keep reading to find out how this all works in the United States...
~ A guest post by Danielle Roberts
Migraine is more common than you might think. According to the Migraine Research Foundation, about 12% of Americans suffer from migraine attacks. They affect women three times as often as men. Although migraine frequency and severity tend to peak during your 30s, they can affect people of any age.
If you suffer from migraines and are enrolled in Medicare, here’s what you should know about how Medicare covers migraine headaches.
A neurologist, which is a doctor who specializes in conditions of the brain, can usually diagnose a migraine based on a physical exam and review of your medical and family history. *1*
However, if you have especially severe attacks or other unusual symptoms, your doctor may order additional tests to confirm a migraine diagnosis. These may include blood tests, CT scans, MRI studies, or even a lumbar puncture.
Medicare has two parts:
Doctor visits, including specialist care, and outpatient lab and imaging tests are covered under Part B.
After you meet your once-annual Part B deductible, Medicare will cover 80% of the cost of diagnostic tests for migraines. You will pay the other 20% of allowable charges. Beneficiaries who enrolled in a Medicare supplement will have some or all of that 20% covered for them by their supplement insurance company, depending on which plan they choose.
Some Medicare beneficiaries opt to get their coverage through a Part C Medicare Advantage plans instead of Original Medicare. If you enrolled in a Medicare Advantage plan instead of Original Medicare, you may pay a copayment instead of a coinsurance amount for these services. It’s important to consult your Advantage plans Summary of Benefits to read about how it covers lab-work and diagnostic tests. This will let you know what costs to expect when you arrive at the lab facility for testing.
Migraine treatment has two parts: Preventing and reducing the severity of the attacks and controlling the symptoms during an attack. *2*
Most migraine treatment involves prescription medications. If you have frequent, severe headaches lasting more than 12 hours, you may be a candidate for preventive drug therapy. These medications can include beta-blockers, amitriptyline and anti-seizure drugs.
Another drug approved by the FDA for chronic migraines is Botox. Medicare may cover Botox for chronic migraines if ordered by a Medicare doctor.
Other medications are given just before or during a migraine attack to help control the pain and symptoms associated with migraine headaches. These might include pain medications, self-injectable or oral triptans or anti-nausea medications.
If you have a severe migraine attack and get care in an urgent care department or emergency room, Medicare does cover allowable charges related to your migraine treatment. This includes any prescription medications you are given during your stay, which will fall under Medicare Part B because the drug is being administered in a clinical setting. You are responsible for your deductible plus 20% of allowable Part B charges for approved medications.
Any outpatient drugs used to treat migraines will fall under Medicare Part D. This is a voluntary prescription drug program that gives Medicare beneficiaries access to retail prescription medications at a reduced cost.
Patients can get this coverage as a stand-alone plan to complement Original Medicare or as part of a Medicare Advantage plan. Although Part D plans must all follow Medicare’s guidelines, the premiums vary based on which plan you choose. You may have to pay an annual deductible and copayment or coinsurance amount for each migraine medication.
It’s important to note that not all prescription drugs are covered by all Part D plans. Each plan has its own formulary or list of covered drugs. If you routinely take migraine medications, check the formulary of any plan you are considering to be sure your medications are covered.
We should also mention that there is a brand-new once-monthly self-injectable drug known as Aimovig that has been shown to help prevent severe migraines. Because the Aimovig has just recently been FDA approved, Medicare does not yet cover this treatment. However, there is hope that this treatment will be added to the list of Medicare-approved migraine treatments in the near future.
If your doctor prescribes Aimovig before it is added to the existing Part D formularies, you can file an exception with your drug plan to see if they will cover it for you now.
Some Medicare Advantage plan members have access to the Silver Sneakers gym and fitness program. If your doctor recommends regular exercise to help prevent migraines, you can use participating fitness clubs and gyms for free.
Danielle Roberts is the co-founder of Boomer Benefits, where her team helps Baby Boomers navigate their new Medicare benefits.
*1* Not all Neurologists deal with migraines, so make sure you find one that does.
*2* I would say treatment has three parts: prevention, aborting the pain phase or progression of the attack and managing symptoms.