Nurtec Health Insurance Denial

• Received a Nurtec Health Insurance Denial? Contact Us
• How Does Nurtec Work?
• How Much Does Nurtec Cost?
• Is There a Generic Drug for Nurtec?
• Do Insurance Companies Cover Nurtec As a Treatment for Migraines?
• Contact the Law Offices of Scott Glovsky if You Receive a Nurtec Health Insurance Denial

Received a Nurtec Health Insurance Denial? Contact Us

More than a billion people across the globe suffer from migraines. The World Health Organization classifies migraine as one of the 10 most disabling medical illnesses, characterized by debilitating attacks that can last from four to 72 hours. In addition to “pulsating” headaches that are moderate to severe in pain intensity, migraine symptoms may also include nausea, vomiting, and sensitivity to sound or light. Approximately 90 percent of those with migraines are unable to work or function normally during a migraine. 

In June 2019, the manufacturer Biohaven submitted two new drug applications to the FDA for Nurtec ODT. In February 2020, the FDA approved Nurtec for the treatment of acute migraine, with or without aura. In May 2021, the FDA approved Nurtec for the preventive treatment of episodic migraines in adults. This article addresses Nurtec health insurance coverage claims and denials, while also covering the necessary steps for action after receiving a Nurtec health insurance claim denial. If you have received a Nurtec health insurance claim denial, you could benefit from contacting the Law Offices of Scott Glovsky.

How Does Nurtec Work?

Nurtec ODT (Rimegepant) works by blocking the calcitonin gene-related peptide (CGRP) receptor, which plays a key role in migraine pain and other migraine-related symptoms. CGRP is a protein released during a migraine, causing blood vessels in the brain to dilate and leading to pain. Nurtec blocks this protein and can be taken to treat acute migraine attacks or as a preventative measure for episodic migraines. 

As a preventative treatment, Nurtec can be taken every other day to significantly reduce the number of monthly migraine days. When taken at the onset of a migraine, Nurtec can help relieve the pain and other symptoms of a migraine, allowing individuals to return to their normal activities. Frequently asked questions regarding Nurtec can be found here.    

How Much Does Nurtec Cost?

The retail price of Nurtec is $1,029. That said, your cost of Nurtec will depend on insurance coverage, the pharmacy used, and manufacturer’s coupons or programs that can reduce the price. The dosage strength can affect the price (Nurtec comes in 75 mg and 100 mg), and the price can be lower when purchased in larger quantities. There are patient assistance programs that can help patients who are unable to afford Nurtec.

Is There a Generic Drug for Nurtec?

There is currently no generic drug available for Nurtec because Pfizer holds the patent that does not expire until March 2039. There are, however, other CGRP inhibitors available to treat and/or prevent migraines, including:

• Ubrelvy (Ubrogepant)
• Qulipta (atogepant)
• Aimovig (erenumab) as an injectable 
• Ajovy (fremanezumab) as an injectable
• Emgality (galcanezumab) as an injectable

Do Insurance Companies Cover Nurtec As a Treatment for Migraines?

Whether your insurer will cover Nurtec as a treatment for migraines depends on several factors. How you get your insurance, which pharmacy you use, and whether your insurer deems the drug medically necessary will all factor into whether you will be approved or denied for your Nurtec prescription. If you have Medicaid (AKA Medi-Cal in California), a government health insurance program for low-income individuals and families, your Nurtec will likely be covered. 

If you have Medicare, the federal health insurance program for individuals over 65, Nurtec will likely be covered; however, the level of co-pay you have will be determined by whether you have a Medicare Advantage Plan (Part C) or a Supplemental Plan (Part D), as well as certain other factors. If you have commercial private insurance through a company like Kaiser Permanente, Anthem, Blue Shield, Healthnet, Aetna, UnitedHealthcare, or a Medi-Cal Managed Care Plan, whether your Nurtec will be covered depends on the individual company’s coverage standards. 

If you are on an ERISA (Employment Retirement Income Security Act of 1974) health insurance plan, which is provided by most private employers, then you must exhaust your administrative remedies through the appeals process if your claim is denied, and you should definitely involve an attorney in the process. If your plan is non-ERISA, you also have other options once you know why your claim was denied. 

Health insurers evaluate coverage requests based on internal medical or pharmacy policies that their own pharmacists and other medical professionals research when the FDA approves a new drug. Internal clinical policies are developed to determine whether a drug is medically necessary, experimental, or investigational. Once these policies are developed, they are brought before a group of external doctors for a vote. Unfortunately, this process can be less than straightforward, as the doctors may receive financial incentives or promises of employment to vote in a way that benefits the insurers. 

Prior authorization is often required by insurers, and this prior authorization may include step therapy. Step therapy requires a patient to take an alternative (often less expensive) drug for at least 60 days. In some cases, two alternative drugs are required through step therapy. If a drug is deemed not medically necessary, it may also be considered experimental or investigational, depending on policy definitions. 

As you may have gleaned, all of these guidelines are extremely subjective, and insurers have a great deal of leverage over what they choose to deem investigational, experimental, or not medically necessary. Insurers, however, do have certain duties to their members. The insurer has a duty to thoroughly investigate claim requests, fully inquire into all possible reasons that might support care requests, promptly respond to claim requests, and appoint and employ qualified medical professionals to make informed decisions regarding claim reviews.  

Contact the Law Offices of Scott Glovsky if You Receive a Nurtec Health Insurance Denial

Receiving a Nurtec health insurance claim denial can be frustrating. It can also make you (rightfully) angry and upset. You faithfully pay your health insurance premiums every month, then when you need your insurer to step up and approve a drug your doctor believes is necessary for your health, your insurer balks. 

The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for decades. Our firm focuses on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. We believe that each client deserves justice, and we fight for that justice by holding wrongdoers accountable.