Medicare should cover Botox injections for migraine if it is deemed medically necessary. You may need a prescription or referral by a medical professional who participates in Medicare.
Botox is an injectable drug made from a type of bacteria called Clostridium botulinum. It temporarily paralyzes muscles by blocking certain chemical signals from specific nerves.
While Botox is commonly known for reducing wrinkles, the Food and Drug Administration (FDA) has also approved Botox for treating chronic migraine in adults. It may also be used off-label for children and teenagers.
Migraine, especially when chronic, can significantly affect your quality of life. Read on to learn when Medicare covers Botox for migraine, which part of Medicare provides the coverage, and what to expect regarding cost.
Because Botox is an FDA-approved treatment, Medicare should cover it in most cases, as long as your doctor can verify that it’s medically necessary to treat your condition.
This is because Original Medicare, which is made up of Part A and Part B, covers procedures and treatments deemed medically necessary to prevent or treat a health condition.
Part A covers services while you’re in the hospital, whereas Part B focuses on outpatient procedures. So Part B is more likely to cover Botox injections.
To get coverage, your doctor will need to show that your migraine is chronic and that other treatments have not been effective.
According to the Centers for Medicare & Medicaid Services (CMS), your medical record must show that you have an official diagnosis of migraine and experience at least 15 or more headache days per month, at least 8 of which must have migraine features.
Your doctor must also specify how many injections they want you to get, the recommended dosage, and how often.
Learn more about Medicare coverage for Botox.
Out-of-pocket Botox treatments for migraine can be pricy. The cost of Botox is about $1,298 per 200-unit vial.
Even if your coverage with Medicare is approved, you’ll have to reach your 2024 monthly deductible of $240. After that, Medicare should pay 80% of the cost.
You may also be able to use a Medigap policy to reduce some of your Part B costs. Medigap is supplemental insurance along with Original Medicare.
Another option is Medicare Advantage (Part C). These plans should provide the same coverage as Original Medicare, but your cost will vary by plan.
Botox can treat migraine because it’s injected into the areas of the head and neck that are involved in migraine pain, where it blocks certain neurotransmitters involved in muscle contractions.
Essentially, Botox injections can prevent the initial migraine signals from reaching your brain. However, Botox injections for migraine can cause side effects. These include bruising, swelling, and neck stiffness.
You may also need to undergo electromyography to identify exactly where you should receive an injection. Medicare Part B should cover this diagnostic laboratory test if it is approved as medically necessary.
Medications for migraine should be paid for under Medicare Part D, which covers prescription drugs.
However, the specific drug must be included in the Part D formulary (list of covered medications), and your out-of-pocket cost will depend on the tier that the drug has been classified into.
Some Medicare Advantage plans also include Part D coverage. You can research plans available in your area and what they cover on the Medicare website.
Note that Medicare doesn’t cover acupuncture or massage therapy for migraine, so you’ll need to pay for these services out of pocket if you’re interested in then. Medicare also doesn’t cover newer treatments for migraine like neuromodulation.
Learn more about making sense of Medicare prescription drug lists and preventive and acute treatments for migraine.
Migraine can have a significant effect on your quality of life, especially if you experience episodes frequently. While Botox is commonly known for reducing wrinkles, the FDA has also approved it for treating chronic migraine in adults.
Medicare may cover Botox injections for migraine relief if a participating healthcare professional deems them medically necessary and can provide evidence of this fact.