If you've ever been prescribed a CGRP biologic and then spent weeks or months in insurance limbo before getting it — or if you gave up before the medication ever reached your pharmacy — you've experienced prior authorization firsthand.
Prior authorization, or PA, is the process by which health insurers require clinicians to get pre-approval before covering certain medications. It exists for cost-control reasons. For patients, it often feels like an obstacle course.
Why CGRP medications require prior authorization
CGRP biologics are expensive. At list price, injectable CGRP medications cost $600–900 per month. Insurers routinely require prior authorization before covering them, and the requirements are substantial.
A typical PA for a CGRP biologic requires:
- A documented diagnosis of episodic or chronic migraine
- Evidence of adequate trials of multiple first-line preventive medications (usually 2-3), with documentation that they failed or caused intolerable side effects
- Confirmation that the patient meets minimum frequency criteria (usually 4+ migraine days per month)
- Specific diagnostic codes and clinical notes formatted to meet the insurer's standards
- Often a letter of medical necessity written by the prescribing clinician
Getting all of this right, submitted correctly, and followed up on is a significant administrative burden. Most primary care offices don't have the resources to manage it. Many neurology practices do, but the wait for an appointment can be 6-8 months.
What happens when PA goes wrong
The most common outcome when PA isn't handled properly: denial.
First-round denial rates for CGRP medications at some insurers exceed 50%. This doesn't mean the medication is inappropriate for the patient — it usually means the documentation was incomplete, the wrong diagnostic code was used, or the evidence of prior treatment failures wasn't formatted to the insurer's requirements.
Patients who receive denials have the right to appeal. But appeals require more documentation, more follow-up, and often a peer-to-peer review call between the prescribing clinician and an insurer's medical director. Most patients who hit a denial simply give up.
This is the gap Wellday was built to close.
How Wellday handles prior authorization
Prior authorization isn't an afterthought at Wellday — it's a core operational competency. When your care plan includes a CGRP biologic that requires PA, we handle the entire process:
Documentation preparation. We compile the clinical documentation in the format each insurer requires — diagnostic codes, treatment history, medical necessity language.
Submission. We submit the PA request on your behalf through the appropriate channel for your insurer.
Follow-up. We track the status and follow up proactively rather than waiting weeks for a decision.
Appeals. If a PA is denied, we file the appeal. We don't accept first-round denials as final.
Manufacturer savings cards. For commercially insured patients who are approved, most CGRP biologics have manufacturer savings programs that bring the copay to $0-5 per month. We coordinate enrollment in these programs so you don't have to.
The result: most of our commercially insured patients pay $0-5 per month for their CGRP medication, compared to $600-900 at list price.
What if you don't have commercial insurance
If you have Medicare or Medicaid, CGRP access is more complicated. Coverage varies significantly by plan and state, and manufacturer savings cards don't work with government insurance.
If you're uninsured, cash-pay options exist. Some manufacturers offer patient assistance programs. The landscape is more complex but not impossible.
During your Wellday consultation, your clinician will assess your specific insurance situation and map out the most viable path to treatment for your circumstances.
The bottom line
Prior authorization is the main reason patients with appropriate clinical indications for CGRP therapy don't receive it. The process is manageable — it just requires clinical expertise, administrative bandwidth, and persistence that most patients and many providers don't have.
If you've been told you need CGRP therapy but haven't been able to get it covered, or if you're just starting the conversation with a clinician, build your free migraine profile and let Wellday handle the hard parts.