My health insurance keeps denying me coverage for ADHD meds - Please, anyone help

[thespeedboy]

I'm 30 years old and have just been diagnosed with ADHD about 2 weeks ago. I'm a high school teacher in Arkansas. My insurance is ARBenefits - I'm on the "classic plan," which is a middle-of-the-road HDHP option. You can see all the info here. My plan's benefits PDF is here, and the preferred drug list is found here. The insurance company's explanation of reference pricing can be found here.

Here's the rundown on what's been happening so far:

• Wednesday, 12-2:

1. Got ADHD diagnosis from my counseling therapist, scheduled an appointment with Dr. for the next Wednesday afternoon. Life is good and things make sense. I feel hopeful for the first time in a while.

• Wednesday 12-9:

1. Saw Dr., he agreed that I had ADHD, wrote me a prescription for Vyvanse 20mg and cancelled my old prescription for Bupropion, which I've been on for a while as an antidepressant because I was diagnosed as depressed before we figured out I had ADHD, but bupropion in higher doses makes me feel awful and wouldn't play well with other ADHD meds. I still had 14 days worth of it. Made me a little uncomfortable to cut that lifeline, but I was excited to try to actually treat the problem of ADHD rather than the symptom of depression.
2. I went to Walgreen’s, only to be told that my insurance is refusing to cover my medication because I’m too old. I freak out and have a little meltdown and leave, embarrassed, with the knowledge that they may cover the medication if they got a preauthorization, whatever the crap that is. Without insurance the medication is $400/month, which is about 15% of my income. Uh, nope. Unfortunately, I learned about the preauthorization mere minutes after the clinic was closed for the day, so I couldn’t do anything but wait.
3. I also picked up my regular prescription for fluoxetine (my other antidepressant that I'm staying on), and once I get home I realize that they screwed up my prescription and only gave me 30 days’ worth instead of 90 days’ worth. I call and ask what to do, and I end up having to drive back up to Walgreen’s and wait in their drive-thru for 15 minutes to get the rest of my prescription filled. Grand.

• Thursday 12-10:

1. Spent hours on the phone with my insurance, doctor’s office, pharmacy, and lord knows who else trying to figure out what was wrong. Had multiple meltdowns and lost my temper. Eventually I manage to get the message through to my doctor that they need to send a preauthorization to the pharmacy. They also tell me to come get a Vyvanse discount card from the doctor’s office.
2. I go to the clinic and get the discount card. They’re still working on the preauthorization, but the card is supposed to be good for the first month for free, so I figure I’ll go get the first month filled and start my new medication and get the ball rolling, and figure out the payment later.
3. I go to the pharmacy and give them the discount card, asking them to run it as secondary insurance as I’ve been told to do. I end up getting told that they can’t fill it because, according to my insurance company, “the medication is only for people 26 and under, they won’t cover anything otherwise.” Okay, so now I know that my insurance is saying that adult ADHD doesn’t exist. Great. Nice to know what I’m working with. I go home and cry, because it’s already too late in the day to do anything else.

• Friday 12-11:

1. Got a phone call midmorning that my preauthorization had been denied. So, for reasons that I am forbidden to know, the medication that my doctor says would be best for me is not allowed by my insurance. Great. The nurse who called talks me through finding the document that lists which medications ARE covered by my insurance, and I send it to her so she and my doctor can go over it.
2. After lunch I get a call saying that they have written me a new prescription for Adderall, with the option to fill it generic. I have to go pick it up in person at the clinic because evidently having ADHD is like the pharmaceutical equivalent of having swear words tattooed on your face.
   
3. I pick my prescription up at the clinic, and get out as fast as I can. No problems. It’s a good clinic.
4. I go to the pharmacy again, and they tell me the exact same crap: Over 26, not covered. The pharmacist on duty is awesome and calls my insurance and harasses them for a drug that WILL be covered, and comes up with a generic version of Focalin XR, dexmethylphenidate XR 20mg.
5. I stand there in the pharmacy and call the clinic and they say they can get me that prescription today, so I haul butt across town to get the new prescription. Before leaving Walgreen’s I buy some Reese’s candy to give to the nurse at the clinic who has been dealing with all of this because she’s handling everything WAY better than I am.
6. I get to the clinic and have to wait a bit to get the prescription, but no big deal. Reese’s delivered without a hitch, too.
7. I get back to the pharmacy and find out that my prescription doesn’t matter anyway, because they don’t even have the freaking medication I’ve been prescribed, and they won’t have any more until freaking January.
8. They call other pharmacies and nobody has it.
9. I leave and call CVS, because I guess Walgreens policy says never to call CVS, I dunno. I get put on hold and start driving that way, because I am picking up dinner from a restaurant next door to the CVS anyway.
10. Twenty minutes later, they answer the stupid phone as I pull into the parking lot. I tell them what happened with having been on hold for 20 minutes and tell them I’ll just come talk to them inside.
11. They also don’t have it, and won’t fill the prescription. I have yet another meltdown. I apologize for my moral failures that have led me to not be rich, and explain that clearly becoming a teacher was wrong of me and I should have pursued the higher calling of being a crack dealer. (In hindsight, that might have been interpreted to be an attack on pharmacists, which it in no way was meant to be. Whoops.)
12. Now it’s late and I have no prescription filled and am stressed and sad and feeling worthless and I am pretty much just ready to give up and say “f*** me for having ever tried to better myself” and just give up. I just give up.

• Saturday & Sunday 12-11 & 12-13: Everyone is closed over the weekend, so I just try not to worry about any of it.

• Monday 12-14:

1. Called clinic first thing to let them know about how none of the pharmacies have the medication. Still waiting to hear back as of lunchtime. Who knows what comes next. Ugh.

Can anyone please help me figure out what the crap to do? I am NOT at all comfortable or fluent in any of this mess. Bureaucracies are the cancer of society, but we have to navigate them from time to time. Unfortunately, my unmedicated ADHD makes navigating a bureaucracy rather difficult. Please, anyone, please help.

 

[munyaku]

@thespeedboy You probably need a PA for either the med itself, the diagnosis or the dose. If this is your first time on meds for adhd, they may require a different series of lower cost generic medications before they'll pay for something like Vyvanse.

 

[babyboomer54]

@munyaku I used to help people exactly with this shit. Because they denied for whatever reason ask the insurance do they allow "prescriber appeals to the denial decision?" And if so how many levels are there aka how many times can my dr submit new info. Use those exact words because they are playing games with you. If they do, go to your Dr. and ask them to do a "preauth denial appeal". They dont have to but they usually do. It means more paperwork for the Dr. As they have to prove why they think you for sure need this med to the insurance company reasoning. Then. And I do not mean to say this will happen BUT if it does and they allow 2nd level, 3rd level have your Dr. Exhaust those. Usually 2nd and 3rd the decision is reviewed and completed by a outside source that yes the insurance company contracts but they are supposed to be impartial and there might he some success.

-If they do not allow appeals and its a complete denial for ANYONE past a certain age your next step is to see if there are any patient assistance programs that can help BECAUSE OF THIS EXACT REASON. They all have different rules. You can see if one is available for any med on needymeds.org and call them for help and to put you in direct contact with whatever one can help.

 

[babyboomer54]

This is if the focalin or generic adderall don't work for you and you need a extended release drug which Vyvanse is and the reason a lot of compamoes.dont want to pay kinda like ehhhj the others are good enough have them take that even if they aren't as all people are different. Now your deal is to just get the generic drugs and find a pharmacy with those in stock which isn't terrible your almost done!

 

[kupdiane]

@thespeedboy I have ADHD-I and was diagnosed as an adult and I absolutely can feel your pain. I know EXACTLY what you're going through and have fought and struggled in almost the exact same way you've been struggling (and also some other crap that you might still encounter in the future). I've had the same meltdowns and the same shame-spirals and the same agonizing times in pharmacies and on hold and everything you've described. I've even had a pharmacist YELL AT ME FROM ACROSS THE ROOM when I tried to get them to fix a problem, and I still for the life of me do not understand why, but oh boy did it trigger a massive meltdown on the drive home.

It is BONKERS how much it feels like the system is built to be hard for ADHDers in particular to navigate, plus the stigma, plus the controlled substance issues, plus misinformation about how ADHD works and adult ADHD being a thing, etc. It's WILD. And it shouldn't be this hard.

Here is what I've learned in my struggles over the last few years: You don't have to use your insurance. Like, at all. You can purchase your medication without insurance and bypass that insurance problems entirely. They are not the arbiter of what medication you are allowed to have... they just can decide what medication they will help you pay for.

There are some ADHD medications that are much more affordable (generic instant release adderall and generic instant release ritalin for example) and also much more likely to be carried at a pharmacy. You can also use discount cards INSTEAD of insurance. I use NOWRX, and some pharmacies have their own discount cards you can ask about. Many doctors and prescribers also have access to discount cards that they can give their patients as well.

So my suggestion is to stop trying to go through your insurance at all for this and instead focus on finding a more affordable medication that you can pay for out of pocket. Some doctors are hesitant to prescribe the instant-release versions of the medications because those are the ones most frequently getting abused, but those are also the least expensive (and ironically also the one most often covered by insurance? because REASONS?!?!)

I basically gave up trying to use my insurance for my ADHD medication except for the one type that they cover (the inexpensive generic IR ritalin). My insurance only covers certain meds, but not others in ways that don't make sense to me and they don't give good reasons. I've been trying to improve my treatment by finding a better medication but I just can't afford it, so I'm stuck with partial treatment, and a few times I paid full price to try other medications to at least know if those were better or not, but then ran into problems with pharmacies having it, or giving me the wrong medication (This is how I learned that even though methylfenidate ER is distributed as a generic for concerta, THEY ARE NOT THE SAME THING. and no one tells you this. Ugh. My doctor was like "well, let's switch you from concerta to Methylfenidate ER and I had to look at my bottle and do a double-take because uh... that's what I'd been taking as a "generic for concerta", and apparently they are not actually the same and it's very difficult to get the one authorized generic for concerta, and brand name concerta is very very expensive).

For what it's worth, it's very common for ADHDers to be on both a low dose of buproprion and an ADHD medication at the same time. I am in a few ADHD support groups and this is probably the most common combo I've heard people talk about and I take both as well. The idea isn't that they "don't play well together", it's more that they both interact with the same neurotransmitters and they reinforce/support each other and potentially mean you can take lower doses of both meds and do better that way. I believe it helps me manage the fact that my ADHD meds are not the perfect fit for me and helps me have a more stable baseline brain. You might consider talking to your doctor again about taking both.

Sorry my response is long and rambly but seriously I feel your pain and I really really hope that you can find a way to navigate this that works for you. I am taking a break from trying to make my situation better until after the new year because I just can't handle the stress of trying to deal with this crap on top of the stress of the holidays. Good luck. you are not alone.

 

[skyybluegirl]

@thespeedboy Judging by the formulary wording that these drugs are excluded from classic coverage, I wouldn’t hold my breath for a PA. There are different levels of rejections, an excluded drug, that’s actually called out as excluded on your drug list... the phrase “hard stop” comes to mind. ADHD meds not being covered over the age of 26 is not uncommon. If they’ll let you continue appealing, I would follow that path. Make sure your doctor knows the covered med is out of stock. Is there a mail order pharmacy you can order from?

If your coverage is employer based you can try going through your HR. Or writing a letter to the insurance pleading your case. These can be hail Mary’s and take weeks to review, but I’ve seen them work. It kind of depends how much money your plan sponsor has to play with. Tight budget means tight formulary, unfortunately.

 

[thespeedboy]

@skyybluegirl Why the fuck are ADHD drugs not covered for people over 26?!

 

[skyybluegirl]

@thespeedboy Oh I have no clue I’m not in a clinical position. But I do know that as much as business and all that bs comes into play with formularies, they do have medical professionals staffed. It isn’t Mr. Insurance making the call on his own. They do reference medical resources and consult clinicians. That’s why the PA information has to come from the doctor’s office and the results are returned back to them.

 

[kupdiane]

@skyybluegirl It totally doesn't make sense that they won't cover it after the age of 26 if they cover it before that age. ADHD is something we have our entire lives. It's not something that a person "grows out of" or anything.

If they stop covering it for some sort of "business reason", that's also really frustrating.

*sigh*

I wish things were better and that insurance and medical research were more aligned.

 

[beautyfromathistle]

@thespeedboy Vivanse is very expensive. Try dexadrine er. One is a prodrug to the other. Dexadrine is cheap without insurance. Vivanse isn't snortable, that's the only real appeal to drs. Its lysine bonded to dexadrine, split slowly in the liver.