*UPDATE POST 69* Medication no longer covered on insurance formulary

[LoveBWVVBR]

*UPDATE POST 69*

We just received information that our child's monthly medicine will no longer be covered on our insurance formulary. We were already paying over $180 a month for this (generic!) medicine. Going to another generic isn't possible as this particular medication had a host of generics disallowed as substitutes about 2 years ago. Those generics didn't work the same. Only the one our child takes works well. I can't imagine what it will cost without the insurance rate if it's $180 a month WITH the insurance rate. Also, without it being on the formulary, does that mean that we pay OOP and then it doesn't even go towards the deductable? We have a high deductable health plan, but in the past the $180+ a month went towards the deductable.

What choices do I have here? I'm guessing an appeal won't be possible. I'm don't even know if I can order it from Canada as it's technically controlled (ADHD med). Thank you for any guidance.

 

[Hikergirl]

I know how you feel, our medications aren't covered and don't count toward our deductible but do count towards the OOP max. Its definitely sticker shock for some.
Call the manufacturer of your ds's meds, they may have a program to help with the costs.

 

[jtobykrauss]

You can file an appeal with the insurance company do to the fact the other med's do not work for your son you will need to do some research on the insurance company's and what is needed for this appeal. Also you will need the doctor who prescribes the mess to write a letter explain why this medication is needed and how the other meds don't work and why etc. Not sure what state you live in but diiferent states have difference regulations on this stuff. I deal with Insurance companies all day long and you really can't go wrong trying to fight for what you need my DS also has ADHD and I know how important the right med can be it took us about a year and a half to find the right one. If you have any question feel free to PM me if I can help you I will.

 

[BruinEd03]

Sometimes the pharmacies themselves will have coupons to help you out if insurance doesn't cover the medication. I would have a chat with them to see if they can help out. Also, shop around from pharmacy to pharmacy (especially since it's not covered). You'd be surprised at how much medication price varies.

http://www.consumerreports.org/drugs/6-tips-for-finding-the-best-prescription-drug-prices/

 

[SunnieRN]

Drug manufacturers are very generous helping those who can not afford a medication, obtain it. I would get the phone number for the manufacturer and find out if they have a program while also working with your sons doctor to file an appeal. Best of luck to you!

 

[FreeDiningFanatic]

You can file an appeal with the insurance company do to the fact the other med's do not work for your son you will need to do some research on the insurance company's and what is needed for this appeal. Also you will need the doctor who prescribes the mess to write a letter explain why this medication is needed and how the other meds don't work and why etc. Not sure what state you live in but diiferent states have difference regulations on this stuff. I deal with Insurance companies all day long and you really can't go wrong trying to fight for what you need my DS also has ADHD and I know how important the right med can be it took us about a year and a half to find the right one. If you have any question feel free to PM me if I can help you I will.

Very well stated above. When writing your appeal, assuming you have commercial insurance through an employer, I would repeatedly make reference that your employer has selected this insurance carrier.... Insurance carriers respond more favorably to appeals from the member than they do those originating from the health care provider. In this case, you, via your employer, are the consumer. This isn't to say you shouldn't use supporting documentation from your physician's office.

 

[MomToOne]

You need to read your insurance documents. If you don't have them, ask your HR person at work or whoever else you get your coverage through for them. With my insurance, I actually have 3 "tiers" of coverage - very few things are completely unavailable on the formulary, but I have had a problem with several of my medications being put into "Tier 3" where they cover some of the cost, but I pay a good chunk as well. When you say your child's medication is being removed from the formulary, I am not sure if you mean maybe it is just being removed from the bottom tier and into a higher one, or if they are going to stop covering it completely.

Also, look into whether or not your insurance has allowances for the drugs to be covered under "step therapy", where certain drugs that are not otherwise covered can be covered once you jump through some hoops to show other drugs don't work properly.

 

[LoveBWVVBR]

You need to read your insurance documents. If you don't have them, ask your HR person at work or whoever else you get your coverage through for them. With my insurance, I actually have 3 "tiers" of coverage - very few things are completely unavailable on the formulary, but I have had a problem with several of my medications being put into "Tier 3" where they cover some of the cost, but I pay a good chunk as well. When you say your child's medication is being removed from the formulary, I am not sure if you mean maybe it is just being removed from the bottom tier and into a higher one, or if they are going to stop covering it completely.

Also, look into whether or not your insurance has allowances for the drugs to be covered under "step therapy", where certain drugs that are not otherwise covered can be covered once you jump through some hoops to show other drugs don't work properly.

It's being removed. The exact language is "this medication will not be covered by your health plan as of 7/1/2016"

DD's pediatrician since birth literally just left the practice in May. We are now with his partner, and relying on her to help me with an appeal might not work. She agreed to keep prescribing what DD's original ped. prescribed for DD, but beyond that I'm not sure what she'll do to help. It took us a long time to find the correct meds. DD is very thin, and playing around with doseage/drugs isn't a safe thing to do to her. I guess I have to appeal this asap and hope that it works.

All that said, has anyone had luck going through a Canadian pharmacy? I don't even know if that's an option with ADHD meds since they're technically controlled, but if it's a safe option I'd be willing to try.

 

[tiggergal15]

If your DDs doc is caring ...they wil do what is called a Prior auth.show them the paper you got and insist it needs a Prior Auth. This where they contact the ins,fill out the paperwork and other requirements for the ins to cover this med. This has to be done by the doc office.
Make sure the office tells the ins your DD has had " treatment failure" with other meds and " it is medically necessary " she stay on current med. And " to stop current med will cause harm to patient". The doc will need a list of previous meds tried and failed so make sure they have that documented.
I do this daily for patients that have formulary changes to get their meds covered.
Be aware..we still get denials and do appeals and sometimes there is just nothing we can do but change meds for patients. But a Prior Auth is worth a try.
Also as pp mentioned...contact the med manufacturer directly- they often have discounts,programs and info to help with cost.
Another thought- shop around pharmacies- they are not created equal and will have different prices for the same med.
Good luck

 

[Happyinwonerland]

I highly recommend checking to see if the manufacturer offers a coupon or anything. I take a daily thyroid med and I get $10/month off (its a cheap med to begin with). I have to carry an epipen for DD's peanut allergy, and we get a coupon that takes a huge amount off that (I forget how much but it is significant). It might help some.

 

[LoveBWVVBR]

I highly recommend checking to see if the manufacturer offers a coupon or anything. I take a daily thyroid med and I get $10/month off (its a cheap med to begin with). I have to carry an epipen for DD's peanut allergy, and we get a coupon that takes a huge amount off that (I forget how much but it is significant). It might help some.

I really wish I could get a coupon or other help from the manufacturer, but this drug is the only generic for Concerta and it's made by the Concerta manufacturer. It looks like there is no help unless you qualify for a state program (which we don't). I'm going to try calling the manufacturer on Monday anyway. I'm also going to attempt an appeal. This is all crazy to me. We can't change her meds. I really feel for people on truly life-saving drugs who go through things like this. It's terrible that insurance companies are allowed to do this.

 

[C-CMom]

If you tried the other generics awhile ago, you may want to re-visit what meds are available now (and which are on your insurance formulary). There have been several new medications released in this class (similar in action) in the past couple of years and others are available in generic that previously weren't. If another round of trials becomes necessary, there may be some additional options you didn't have before - one of these may actually be as good or better than your current.

Another question is whether you insurance allows for a "maintenance" supply (usually 90 days) for somewhat cheaper price than if prescription is written a month at a time (if also allowed by your state law). Don't get 90 days worth until you are sure you are sure it is helpful and no problems, though.

General Pediatricians are often very good at ADHD management, but a visit to a Developmental Pediatrician or Child Psychiatrist may provide a bit more info to help you choose a solution (then perhaps resume routine follow-up with the Pediatrician if OK with all of the doctors involved).

 

[MommaBerd]

This is a long shot and probably worthless - but did you make sure that Concerta itself isn't covered? My husband owns a small business and so we rarely stay on the same insurance year after year (because the ins. companies jack the rates up at renewal). Anyhow, some insurance companies ONLY cover brand. It's crazy, but it's true.

ETA: oldest DS is on Adderall and this is the medication we most often deal with.

 

[barkley]

I really wish I could get a coupon or other help from the manufacturer, but this drug is the only generic for Concerta and it's made by the Concerta manufacturer. It looks like there is no help unless you qualify for a state program (which we don't). I'm going to try calling the manufacturer on Monday anyway. I'm also going to attempt an appeal. This is all crazy to me. We can't change her meds. I really feel for people on truly life-saving drugs who go through things like this. It's terrible that insurance companies are allowed to do this.

try calling the manufacturer-they may know of a program even if they don't operate one themselves. look to the fine print on your insurance docs to see what the appeal process is (ds's former pediatrician was able to get some kind of authorization through some process he had to do in order to get us coverage for ds's then adhd meds that were not listed on the formulary). if the doctor is unwilling then it may be time to get someone with more expertise in this area anyway-we've had good luck with pediatric neurologists (they deal with adhd all the time, are well educated about the meds-know how to deal with the insurance companies).

It took us a long time to find the correct meds. DD is very thin, and playing around with doseage/drugs isn't a safe thing to do to her

if worse comes to worse and you have to resort to having your child give some other adhd meds a try, and it's not been tried with your child before-I highly recommend the daytrana patch.

ds tried multiple adhd meds with poor results-he needed a time release type (which I believe concerta and it's generacs are as well?). at the time he began using the patch he was also a VERY thin kiddo. the advantage to the daytrana patch is if you try it and there's not a good result it's all out of their system within about 2 hours of taking off the patch (so no trying a new med, having a negative result and then waiting days on end for the effects to go away). this med REALY helped ds gain some weight as well-we would put it on 2 hours before he started school (actually put it on while he slept) so it's effects were in force when school started BUT not when breakfast occurred (so he started eating a bit more). we would take it off a couple hours before dinner (so again-he started eating a bit more and developing more of an appetite).


good luck to you-it's a pain when insurance companies do this, I personally think it should be illegal to make changes like this mid contract, and at the very least there should be a mandatory 90 pre-notification requirement so patients/doctors have sufficient time to address the issue.

 

[Debbie Jean]

I was in this exact situation a few years ago. Medication that was almost $1000 monthly that could not be changed. You don't need to explain to me why... I totally understand. No options from the manufacturer or other discounts available.

I used a pharmacy in Canada. I would have to go back in my files to find which one it was but I got excellent service from them. The drug was exactly the same but cost just over $200 for a monthly supply. The difference in price is because the government sets the prices... not the pharmaceutical company.

BTW it was also a controlled drug. That made no difference since that designation only applies in this country. I just needed a valid script which was not a problem.

I feel your pain since I've been through this. Will send good thoughts your way for a solution!

 

[LoveBWVVBR]

This is a long shot and probably worthless - but did you make sure that Concerta itself isn't covered? My husband owns a small business and so we rarely stay on the same insurance year after year (because the ins. companies jack the rates up at renewal). Anyhow, some insurance companies ONLY cover brand. It's crazy, but it's true.

ETA: oldest DS is on Adderall and this is the medication we most often deal with.

Just a minute ago the Walgreens pharmacist told me the same thing...call the insurance because sometimes they actually cover the brand but not the generic! That would be crazy, but it's worth a try. I'm calling on Monday. That said, I've never been able to find the brand around here, so I guess I'd have to order it.

The pharmacist also recommended GoodRx so I'm going to see if that gives me a discount. The part that's getting me is that even if I could get it for the same amount or less doing a variety of things, none of this money will go towards our deductable because the medication is no longer on the insurance. That really aggrivates me.

I was in this exact situation a few years ago. Medication that was almost $1000 monthly that could not be changed. You don't need to explain to me why... I totally understand. No options from the manufacturer or other discounts available.

I used a pharmacy in Canada. I would have to go back in my files to find which one it was but I got excellent service from them. The drug was exactly the same but cost just over $200 for a monthly supply. The difference in price is because the government sets the prices... not the pharmaceutical company.

BTW it was also a controlled drug. That made no difference since that designation only applies in this country. I just needed a valid script which was not a problem.

I feel your pain since I've been through this. Will send good thoughts your way for a solution!

Oh wow, good info. I'd love to know which Canadian pharmacy you use if you wouldn't mind PMing me. I'm willing to pursue all options at this point.

 

[tvguy]

Explore the appeal process with your insurance company.
Explore discounts from the drug maker.
Are the other allowed drugs actually generics, or are they alternate drugs that are supposed to do the same thing? By law generics have to have the identical formulation and effect. If they are true generics, you may want to revisit those drugs, often your Doctor can provide free samples to try.

 

[scdak]

Do try Goodrx.com as the pharmacist suggested, for a lot of meds its a great savings, I work in an ED and we look up meds all the time for patients so they can see where the med would be the cheapest in your area. It doesn't help the fact that it doesn't count towards your deductible but at least it could save you some money.

 

[C-CMom]

...often your Doctor can provide free samples to try.

But not typically for "controlled" substances.

 

[serenitynow]

Google Concerta copay assistance programs