Meds vs Insurance Co. | ADHD Information

I agree, I'ts all about the money, #$&@# shame!!!!! Anyways, I'm not going to switch meds on my daughter after we have come sooooo far and she's doing soooo well. I'm looking around for the cheapest price and trying to get Dr to get coupons from med reps, hope that will take the bite out a little.We never have had that happen before. I know some ins. won't cover Strattera cause it's new. Some will only cover stims cause they are older and have proven sucess. So they say any how. Since I have been on this board dosage changes or medacine changes is all I hear on this board. This convinces they are not really that valuable. The side effects of  these can be bad. Our son learns hands on and is being pushed to learn another way. He needs to do it until he get's it. oldtimer38736.3033333333

We also had a problem with our insurance, but our pediatrican went to bat for us & got it approved.

I think it really depends on the Doctor. From what I understand, a Dr. can fill out appropriate paperwork to get insurance to pay for a specific medication for a patient.. its not  a simple little form however, from what my docs nurse told me, it is PAGES long!  If a Dr. filled out the forms everytime the insurance denied a med for a patient, then he would be spending more time doing paperwork than he would seeing patients! I was told by the nurse that my doc would jump through those hoops for heart medications or other life threatening illnesses but not for all meds.

So, what I'm saying is, if you got your doc to go to bat for you, he is worth his wieght in gold!!

sherry

Hi all- My daughter has recently been diagnosed with ADHD and has been  taking Focalin XR (Freebie 30 day sample from Dr.) She has been doing well so far and then I found out that this med is not covered by insurance because it is a New-To-Market drug. They want her to try at least two other known and proven med and fail miserably on them before they even concider covering the Focalin XR.  Using my child as a med "guinea pig" at this point is not an option as she is doing so well. Anybody out their have any suggestions on how to jump threw insurance hoops??? Thanks

I went through that with concerta.. the med worked great for me... Now I'm stuck taking metadate CD which is the same medicine just different delivery system. It also doesnt last as long.. 

The real reason they don't want to cover a medication is because it costs more or they havent negotiated a cheaper price with the pharmaceutical company. Its all about money.

But, I really think insurance is kinda stupid in this situation. On the concerta all I needed was 30 capsules for a 1 month dose.

ON the metadate I have 60 capsules to get the same duration of treatment. they spend more on  the metadate than they would have on the concerta!

I had the same problem a while back when I was perscribed a medication for a fungus under my nail ( ewwwwww!) I was given an oral medication, insurance denied it.. The Doc then had to fill out a bunch of paper work to prove that the medicine was medically necessary. They make the Docs jump through a bunch of hoops also.. it really stinks. He got them to approve it, but geez.. why cant our Docs just do their jobs?

ok off of soapbox now

[QUOTE=justamom] I found out that this med is not covered by insurance because it is a New-To-Market drug. They want her to try at least two other known and proven med and fail miserably on them before they even concider covering the Focalin XR.  [/QUOTE]

The insurance company is not a doctor and they have no right telling her to try other meds first when the doctor specifically prescribed Focalin!

Why pay for insurance if they wont ever pay for anything??

You have to call and fight them for a week before they finally cave in and do their job. You pay for insurance every month incase something ever comes up and when it finally does then they only offer to cover only 10 percent. Anybody agree with me on this?

Our insurance will only cover non-formulary meds if there is a treatment failure on the formulary meds. Treatment failures include things like can't swallow pills, side effects or med not being effective. You might try a methylphenidate on the formulary (see which are available - concerta, metadate, etc). If it does not work then you can have the doc rule out the similar meds and justify moving to focalin. If your child cannot swallow pills, this will really narrow down the choices as well.

You might pay for the focalin until school ends then try the formulary meds during the summer. You can either find an effective formulary med or justify to the insurance company that these don't work. Just a thought.

i have run into the insurance problem myself and i am also looking for some help.  i am an education professional that has an out-patient clinic attached to our school which means we have a psychiatrist on staff 20 hours a week.  we have been unable to get one of our students daytrana, which is the patch, paid for by insurance.  we have written the appeals along with the family and still haven't found success.  this has been going on since september.  i just called Shire, which is the drug company to explain our situation.  the customer service rep was wonderful and is sending out a drug rep to at least help with samples.  she also is going to have her dept who deals with insurance companies contact us to assist us in dealing with medical assistance in PA.  i'm hoping there are also other answers out there that people would like to share with me so we can get this student what he needs.

Do you know if your insurance turned it down completely or if they wanted a prior authorization.  We do this all the time at our office for meds.  Ins companies are a pain in the $#%.  The big thing on this is to keep calling the insurance company.  Find out specifically what they need to approve this medication, letter from the doctor, psychologist ect.  If that doesn't help call the company.  It is Novartis. 

 

Here is some info I found on their website

Enrolling in the Novartis PAP is quick and easy.