Adderall + Prior Authorization

Replies to This Discussion

Permalink Reply by Susan on December 8, 2009 at 10:12pm

I didn't think that Adderall XR came in generic form so make sure it is XR you are getting. Insurance can be difficult and each person's insurance is different. You will learn as you go along. I wouldn't think that it needed prior approval really but. . . You can call the insurance company and ask. Call the number on your card. It may be frustrating getting to the right person. Right down the names of who you talked to in case there is a problem later. You will always have to have a new script each time and it cannot be called in from the MD office. If the pharmacy is calling for the authorization it probably depends on when they do it. I would call back each day asking about it. Pharmacists are in short supply so they are overworked but they still should be pleasant and helpful. You will learn how your insurance works and what it covers.

I don't know if the prior authorization or something may be because they want to give you a different drug that has a generic. Just ask a lot of questions as I don't even understand all parts to my insurance until I have to use them and I am a nurse. We only know what we are familiar with. Good luck. I know you are anxious to get your meds and get started. Just make sure you eat when you take the med even if you are not hungry or you will feel bad from not eating. The first couple of days were rough for me when it wore off but it got better.

▶ Reply to This

Permalink Reply by Jo Ellen on December 9, 2009 at 1:49am

I had the same problem. Part of it is some insurance companies don't allow adults to get this medication without your doctor explaining your need. The first time, it may take a while because it has to go through your doctor and then to your insurance company. Then they will either approve it or deny it. If they deny it, you have to apply for an appeal, which the instruction on how to do it is usually explained on the back side of the denial letter. You usually have 60 days in which to appeal. It involves a little more paperwork from the doctor. I have had three different Blue Cross/Blue Shield insurance companies and they are usually good to work with. Once they get the paperwork from your doctor, they will sent the authorization to your pharmacy. Another reason the pharmacy has a problem with dispensing it is because it is basically 'speed' and they want to make sure you are not going to be selling it on the street. They watch very closely how often you get your prescriptions. They will allow you to fill it a couple of days early, but when it comes up that you may have extra, they will put a hold on letting the pharmacy dispense it to you. I had it happened to me once. They usual will only give you enough for 30 days, whether or not the month has 31 days. I personally think it is a lot of red tape. I am 57 years old and have no idea how to sell it on the streets. But, I am sure there are some bad apples out there that make it so those of us law abiding citizens have to jump through the extra hoops. But, it is the way it is.

Jo Ellen

▶ Reply to This

Permalink Reply by Danielle on December 9, 2009 at 11:32am

Gretchen, I just went through this recently. I took an adderall XR prescription to my pharamcist. It could not be filled due to preauthorization. The pharmacist faxed the doc. The nurse sent for the preauthorization form filled it out and sent it to the insurance pharmacy provider. Normally the process is short by fax. It took several days because of the weekend and Thanksgiving break. It was denied. I called the insurance company like Susan suggested. That's usually the best thing to do. They told me it was not covered because I am over 20. My doc at the time got a letter and they gave me a copy. It stated, " ADD/ADHD medications are not a covered benefit for patients age 20 and up on this member's plan." After reading this I called the insurance company again. I was told the meds and the monthly visits required by the doc are not covered for this diagnosis, because of my age, but I had the right to appeal.

Pharmacy- My pharmacist told me adderall xr generic is NEW. The generic cost to me was $175 a month. The generic cost for regular adderall taking it through the day was $30.00 a month with the generic pharmacy discount. I told the pharamist that I will not be getting the xr and notified my doc's nurse. My doc would not prescribe generic regular adderall, so I got a new doc. I am now taking generic adderall everyday twice a day. It it affordable to me.The insurance company told me how to write an appeal, so I did so and attached my psy. eval diagnosis of ADD. I am still waiting on the appeal. I called the insurance again and asked if appeals are usually granted. They said, no because the contracts states the age limit. They also said it could take a month for a response on the appeal. They told me it was worth trying. We will see. Maybe your doc's office can write the appeal if necessary. The restriction may be age limit or diagnosis, you can find out by calling. I hope this is helpful. The process is overwhelming. My letter from the insurance also stated the diagnosis you have to have to get adderall covered as an adult.

With my old insurance company I had a $10.00 copay with generic adderall. They also had an age limit. I made a phone call. My old doc faxed them info and it was approved quickly. I did not have to write a letter of appeal.

▶ Reply to This

Permalink Reply by Gretchen B on December 9, 2009 at 12:25pm

It is amazing how a few bad apples spoil the bunch! Even when I go buy Sudafed I feel like a criminal now! hah. I'm sticking with BCBS but its "open season" for me now, so I'm looking at all the insurance companies I can pick from and its alllllll so overwhelming. I'm probably going to be sticking with BCBS but there are even a few sub-categories I can choose from with that! Geez. And how is it noon already!?

Jo Ellen said:

I had the same problem. Part of it is some insurance companies don't allow adults to get this medication without your doctor explaining your need. The first time, it may take a while because it has to go through your doctor and then to your insurance company. Then they will either approve it or deny it. If they deny it, you have to apply for an appeal, which the instruction on how to do it is usually explained on the back side of the denial letter. You usually have 60 days in which to appeal. It involves a little more paperwork from the doctor. I have had three different Blue Cross/Blue Shield insurance companies and they are usually good to work with. Once they get the paperwork from your doctor, they will sent the authorization to your pharmacy. Another reason the pharmacy has a problem with dispensing it is because it is basically 'speed' and they want to make sure you are not going to be selling it on the street. They watch very closely how often you get your prescriptions. They will allow you to fill it a couple of days early, but when it comes up that you may have extra, they will put a hold on letting the pharmacy dispense it to you. I had it happened to me once. They usual will only give you enough for 30 days, whether or not the month has 31 days. I personally think it is a lot of red tape. I am 57 years old and have no idea how to sell it on the streets. But, I am sure there are some bad apples out there that make it so those of us law abiding citizens have to jump through the extra hoops. But, it is the way it is.

Jo Ellen

▶ Reply to This

Permalink Reply by Gretchen B on December 9, 2009 at 12:59pm

Danielle,

Thanks for sharing your experience. How did you learn that the authorization was denied - did the pharmacy contact you, or did your doctor contact you, or did the insurance contact you? Or did you have to contact someone to figure this all out?

I can't believe how long the appeals process takes! I looked up the pharmacy benefits for my current insurance, and it said adults can be prescribed Adderal XR with prior authorization (but not Adderall IR). Hopefully there won't be an issue.. I'm not sure how much it will cost. There is a table, and it references another table, and then I click a link and it doesn't work. oy.

Gretchen

Danielle said:

Gretchen, I just went through this recently. I took an adderall XR prescription to my pharamcist. It could not be filled due to preauthorization. The pharmacist faxed the doc. The nurse sent for the preauthorization form filled it out and sent it to the insurance pharmacy provider. Normally the process is short by fax. It took several days because of the weekend and Thanksgiving break. It was denied. I called the insurance company like Susan suggested. That's usually the best thing to do. They told me it was not covered because I am over 20. My doc at the time got a letter and they gave me a copy. It stated, " ADD/ADHD medications are not a covered benefit for patients age 20 and up on this member's plan." After reading this I called the insurance company again. I was told the meds and the monthly visits required by the doc are not covered for this diagnosis, because of my age, but I had the right to appeal.

Pharmacy- My pharmacist told me adderall xr generic is NEW. The generic cost to me was $175 a month. The generic cost for regular adderall taking it through the day was $30.00 a month with the generic pharmacy discount. I told the pharamist that I will not be getting the xr and notified my doc's nurse. My doc would not prescribe generic regular adderall, so I got a new doc. I am now taking generic adderall everyday twice a day. It it affordable to me.The insurance company told me how to write an appeal, so I did so and attached my psy. eval diagnosis of ADD. I am still waiting on the appeal. I called the insurance again and asked if appeals are usually granted. They said, no because the contracts states the age limit. They also said it could take a month for a response on the appeal. They told me it was worth trying. We will see. Maybe your doc's office can write the appeal if necessary. The restriction may be age limit or diagnosis, you can find out by calling. I hope this is helpful. The process is overwhelming. My letter from the insurance also stated the diagnosis you have to have to get adderall covered as an adult.

With my old insurance company I had a $10.00 copay with generic adderall. They also had an age limit. I made a phone call. My old doc faxed them info and it was approved quickly. I did not have to write a letter of appeal.

▶ Reply to This

Permalink Reply by Gretchen B on December 9, 2009 at 1:05pm

Thanks for the advice, Susan. I am definitely going to have to keep an eye on what I eat. I spend about 12 hours/day in the office and tend to only eat chewing gum and almonds in here. :\ maybe I will need to bring in some more food.

I will call the pharmacy today. The pharmacists did seem to be short staffed wherever I went. In fact, everything seems short staffed on the east coast! There are just so many people (I'm originally from the midwest).

Gretchen

Susan said:

I didn't think that Adderall XR came in generic form so make sure it is XR you are getting. Insurance can be difficult and each person's insurance is different. You will learn as you go along. I wouldn't think that it needed prior approval really but. . . You can call the insurance company and ask. Call the number on your card. It may be frustrating getting to the right person. Right down the names of who you talked to in case there is a problem later. You will always have to have a new script each time and it cannot be called in from the MD office. If the pharmacy is calling for the authorization it probably depends on when they do it. I would call back each day asking about it. Pharmacists are in short supply so they are overworked but they still should be pleasant and helpful. You will learn how your insurance works and what it covers.

I don't know if the prior authorization or something may be because they want to give you a different drug that has a generic. Just ask a lot of questions as I don't even understand all parts to my insurance until I have to use them and I am a nurse. We only know what we are familiar with. Good luck. I know you are anxious to get your meds and get started. Just make sure you eat when you take the med even if you are not hungry or you will feel bad from not eating. The first couple of days were rough for me when it wore off but it got better.

▶ Reply to This

Permalink Reply by Danielle on December 9, 2009 at 7:53pm

Gretchen, My doctor's office submitted the preauthorization and they were faxed the deniel letter. They contacted me and I requested a copy. The insurance company put the reason for deniel on the copy. I used this information to help write the appeal. I agree with you the appeals process takes too long.

Gretchen B said:

Danielle,

Thanks for sharing your experience. How did you learn that the authorization was denied - did the pharmacy contact you, or did your doctor contact you, or did the insurance contact you? Or did you have to contact someone to figure this all out?

I can't believe how long the appeals process takes! I looked up the pharmacy benefits for my current insurance, and it said adults can be prescribed Adderal XR with prior authorization (but not Adderall IR). Hopefully there won't be an issue.. I'm not sure how much it will cost. There is a table, and it references another table, and then I click a link and it doesn't work. oy.

Gretchen

Danielle said:

Gretchen, I just went through this recently. I took an adderall XR prescription to my pharamcist. It could not be filled due to preauthorization. The pharmacist faxed the doc. The nurse sent for the preauthorization form filled it out and sent it to the insurance pharmacy provider. Normally the process is short by fax. It took several days because of the weekend and Thanksgiving break. It was denied. I called the insurance company like Susan suggested. That's usually the best thing to do. They told me it was not covered because I am over 20. My doc at the time got a letter and they gave me a copy. It stated, " ADD/ADHD medications are not a covered benefit for patients age 20 and up on this member's plan." After reading this I called the insurance company again. I was told the meds and the monthly visits required by the doc are not covered for this diagnosis, because of my age, but I had the right to appeal.

Pharmacy- My pharmacist told me adderall xr generic is NEW. The generic cost to me was $175 a month. The generic cost for regular adderall taking it through the day was $30.00 a month with the generic pharmacy discount. I told the pharamist that I will not be getting the xr and notified my doc's nurse. My doc would not prescribe generic regular adderall, so I got a new doc. I am now taking generic adderall everyday twice a day. It it affordable to me.The insurance company told me how to write an appeal, so I did so and attached my psy. eval diagnosis of ADD. I am still waiting on the appeal. I called the insurance again and asked if appeals are usually granted. They said, no because the contracts states the age limit. They also said it could take a month for a response on the appeal. They told me it was worth trying. We will see. Maybe your doc's office can write the appeal if necessary. The restriction may be age limit or diagnosis, you can find out by calling. I hope this is helpful. The process is overwhelming. My letter from the insurance also stated the diagnosis you have to have to get adderall covered as an adult.

With my old insurance company I had a $10.00 copay with generic adderall. They also had an age limit. I made a phone call. My old doc faxed them info and it was approved quickly. I did not have to write a letter of appeal.

▶ Reply to This

Permalink Reply by Gretchen B on December 10, 2009 at 1:25pm

Just an FYI - soon after I wrote this, I heard back from the pharmacy. I was able to pick up the medication soon after (i.e., the day after my appointment!) I think it went so fast because my doctor has a secretary to handle paperwork - a lot of them don't, it seems.

I feel great, by the way! Today is my second day on it, and I feel clear-headed, but not jittery like coffee. I have less peripheral distractions - I told my officemate this yesterday, and I'm pretty sure he thinks I'm nuts. We're jammed together in this windowless room and every sound he makes distracts me. He's not trying to distract me, but he's clicking, and stapling, and humming christmas songs (which is kind of hilarious because he's Muslim) but I didn't even notice ANY of this until I actually TRIED to notice. Not sure if that makes sense. I also felt less horrible and anxious after a day of work. Soooo so far so good!

Thanks everyone for your responses, by the way! Blue Cross Blue Shield pulled through on this one, for now, but I'm still getting angry letters about a dental cleaning in August - so who knows what the future holds!

Gretchen

▶ Reply to This

Permalink Reply by Danielle on December 10, 2009 at 6:03pm

Yeah! That's great news. Thanks for the up-date. It is so good to hear about medication success stories.

Gretchen B said:

Just an FYI - soon after I wrote this, I heard back from the pharmacy. I was able to pick up the medication soon after (i.e., the day after my appointment!) I think it went so fast because my doctor has a secretary to handle paperwork - a lot of them don't, it seems.

I feel great, by the way! Today is my second day on it, and I feel clear-headed, but not jittery like coffee. I have less peripheral distractions - I told my officemate this yesterday, and I'm pretty sure he thinks I'm nuts. We're jammed together in this windowless room and every sound he makes distracts me. He's not trying to distract me, but he's clicking, and stapling, and humming christmas songs (which is kind of hilarious because he's Muslim) but I didn't even notice ANY of this until I actually TRIED to notice. Not sure if that makes sense. I also felt less horrible and anxious after a day of work. Soooo so far so good!

Thanks everyone for your responses, by the way! Blue Cross Blue Shield pulled through on this one, for now, but I'm still getting angry letters about a dental cleaning in August - so who knows what the future holds!

Gretchen

▶ Reply to This

Permalink Reply by Danielle on December 10, 2009 at 8:17pm

I got a response from the insurance company today. My appeal was denied, they were careful to note that "this determination was not an issue of medical necessity, but solely based on ......your benefit provision and contract age limitation." I have peace with this decision because I am using the generic adderall and it is affordable. I am very thankful that I have another doc who prescribed the adderall the way I needed it and could afford it. There is a big benefit to taking the XR because you don't have to remember to take another dose. One pill a day is great.

Danielle said:

Yeah! That's great news. Thanks for the up-date. It is so good to hear about medication success stories.

Gretchen B said:

Just an FYI - soon after I wrote this, I heard back from the pharmacy. I was able to pick up the medication soon after (i.e., the day after my appointment!) I think it went so fast because my doctor has a secretary to handle paperwork - a lot of them don't, it seems.

I feel great, by the way! Today is my second day on it, and I feel clear-headed, but not jittery like coffee. I have less peripheral distractions - I told my officemate this yesterday, and I'm pretty sure he thinks I'm nuts. We're jammed together in this windowless room and every sound he makes distracts me. He's not trying to distract me, but he's clicking, and stapling, and humming christmas songs (which is kind of hilarious because he's Muslim) but I didn't even notice ANY of this until I actually TRIED to notice. Not sure if that makes sense. I also felt less horrible and anxious after a day of work. Soooo so far so good!

Thanks everyone for your responses, by the way! Blue Cross Blue Shield pulled through on this one, for now, but I'm still getting angry letters about a dental cleaning in August - so who knows what the future holds!

Gretchen

▶ Reply to This

▶ Reply to This