Have you ever picked up a medication from your pharmacy while in a hurry and been met with major sticker shock? Like you expected your medication to be $4, but the pharmacy tech tells you that your medication requires a prior authorization, and if you have to pay out of pocket, it will be $189? That can be a crushing sensation, especially if it’s for a med that you know you need, and that amount just isn’t in your budget. I have had patients in El Paso and other areas tell me this has happened to them, and it was very stressful for them.

If you ever had this experience when going to pick up your stimulant medication for the treatment of your adult Attention Deficit Hyperactivity Disorder (ADHD), you might be asking yourself: “Why doesn’t my insurance cover my ADHD medication?”

If you have insurance with prescription benefits, you may assume that all medications will be encompassed in this benefit. So, shouldn’t your ADHD stimulant medication, like Adderall, Concerta, or Vyvanse be covered? Well, that can be tricky and not completely straightforward. Under some plans, your insurance may require a prior authorization (“prior auth” for short) before the plan will pay for your medication. A prior auth is documentation that your prescriber fills out to demonstrate why you need a certain prescription filled.

"Without a thorough and convincing explanation of why a particular med is needed, your insurance can deny coverage and require you to pay the full amount for your stimulant med."

Working With Your Behavioral Health Provider to Get Your Insurance to Cover Your ADHD Medication

A medication prior auth is approval obtained from your insurance company saying they agree to pay for the medication your provider has prescribed. Your insurance company, in some cases, requires documentation demonstrating the medication that your provider wants you to take is the best treatment for your condition. The insurance company will review the documentation, and if they agree with the assessment presented, a prior auth is granted. In the case of stimulant ADHD medication, they will want proof that this medication is the cheapest, most effective medication for your ADHD symptoms.

How does your provider convince your insurance company that the medication they are prescribing is the correct therapy for you? Your provider must complete the prior auth paperwork, which can be an electronic or paper form. In this paperwork, your provider must give an accurate description of your “clinical presentation;” that is, what your symptoms are, and how they are impacting you. If your provider is completing the prior auth for stimulant medication such as Concerta, Adderall, or Vyvanse, they will need to discuss your symptoms of ADHD, which may include:

• Forgetfulness
• Losing important items
• Inability to sit still
• Being unable to complete complex tasks at work or school
• Talking over others
• Not listening when being spoke to

Your provider will also need to explain how these symptoms are affecting your work or family life, and why the prescribed medication is the right treatment for you.

Prior authorization paperwork can be time-consuming to complete, but if it’s not completed correctly, the insurance company can reject the request. In that case, they won’t cover the medication, and the patient is responsible for the entire cost of the med. That’s not a good scenario at all.

Unfortunately, I have heard of cases where doctors simply don’t make the time or effort to put in an accurate picture of a patient’s clinical presentation when completing prior auth paperwork. In that case, the prior auth often gets denied. It’s even possible for the prior auth to not get done at all, and then for the doctor’s office to say, “Your insurance doesn’t cover your meds,” without an explanation of why.

At Upper Valley Behavioral Health, our providers are experienced at completing prior auth paperwork for medications, including for ADHD stimulant medications. We understand how important it is for patients to have their medications covered by insurance.

How Patient Assistance Programs Can Help If Your Medication Isn’t Covered

Sometimes, despite sound reasoning and good documentation from your prescriber, your insurance company still refuses to cover the cost of your ADHD medication. While this can be a frustrating situation, there can be alternatives to paying full-price for your medication.

Many drug companies offer a patient assistance program, in which they will cover part or all of the cost of a prescription medication if the patient’s insurance doesn’t cover the medication and the patient shows financial need. With patient assistance programs, there is again paperwork that needs to be completed by the prescriber and also paperwork that needs to be filled out by the patient. At Upper Valley Behavioral Health, we are familiar with patient assistance programs for the ADHD medications we may prescribe. If needed, we can direct the patient to the appropriate paperwork and help explain to them how they can complete their portion.

In the treatment of your adult ADHD, it’s crucial for you to take the medication that you and your provider find works best for your symptoms. When you work with a behavioral health expert that is experienced in helping patients obtain their medications in an affordable way, you are less likely to experience the life disruptions that can come from missing doses of your prescribed stimulant medication.

Have you been considering seeking treatment for your ADHD symptoms? If you live in or near El Paso or Albuquerque, or in any of the other cities that we serve, Upper Valley Behavioral Health can provide the excellent services you require. Please fill out our short application for treatment to get started on the path toward conquering your ADHD symptoms.

Disclaimer: This post is for informational purposes only. It does not replace instructions from your licensed prescriber. Please consult your healthcare provider for guidance on your specific medication regimen.

Tags: adhd medication, adhd meds, adult adhd, adult adhd support, adult adhd medication, adult adhd medication assistance program, mental health, adult adhd awareness, mental health warrior, mental health awareness, medical coverage, mental health insurance, prescription coverage, adhd support

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