United Healthcare not covering certain ADHD meds

[Anonymous]

Did anyone else get a letter from UHC the other day indicating that they will not be covering certain ADHD medications after July 1? Both of the meds we use for our son are on the list -- Daytrana and Focalin. Basically they are saying that Metadate, generic Metadate, and Concerta work just as well, so you are supposed to switch. WTH! People spend months/years trying different meds and finally find one that works well with few side effects, and then this happens. I'm particularly concerned about Daytrana, which we switched to a few months ago with huge improvement over the Focalin (we still use Focalin on weekends sometimes and as a booster). The transdermal delivery system makes a huge difference in our case (lasts longer and is much smoother delivery), so saying that we should use a similar medicine that is capsule form seems ridiculous. The other advantage of the patch is that it can be removed whenever, which you can't do with a pill.

Has anyone ever tried to appeal these types of coverage decisions and had any success? I really hate to mess with our system that has been working so well.

[Anonymous]

Anonymous wrote:Did anyone else get a letter from UHC the other day indicating that they will not be covering certain ADHD medications after July 1? Both of the meds we use for our son are on the list -- Daytrana and Focalin. Basically they are saying that Metadate, generic Metadate, and Concerta work just as well, so you are supposed to switch. WTH! People spend months/years trying different meds and finally find one that works well with few side effects, and then this happens. I'm particularly concerned about Daytrana, which we switched to a few months ago with huge improvement over the Focalin (we still use Focalin on weekends sometimes and as a booster). The transdermal delivery system makes a huge difference in our case (lasts longer and is much smoother delivery), so saying that we should use a similar medicine that is capsule form seems ridiculous. The other advantage of the patch is that it can be removed whenever, which you can't do with a pill.

Has anyone ever tried to appeal these types of coverage decisions and had any success? I really hate to mess with our system that has been working so well.

NO and please don't tell me this!!! We just started on Focalin after years of avoiding it because UHC wouldn't cover it. Now they cover it with a $50 co-pay so we started using it just a month ago and like it. He was on Adderral for years. Tried concerta, it was "eh".

Never tried Daytrana. Now I don't even want to consider it.

[Anonymous]

This is pretty common with many health insurance companies. I have Kaiser and certain meds are out-of-pocket. Try and see if you can get the doc to report to the insurance company that all other options were tried and this is the only medicine that will work for the child.

[Anonymous]

There is usually an appeal process. They want to make you jump through as many hoops as they can legally get away with, but you can eventually get it covered.

[Anonymous]

No but United Healthcare also will no longer cover Occupational Therapy at Goid Beginnings in Falls Church as of July 1, and there is no other in-plan occupational therapist within 30 miles (we are trying to get gap coverage). Wonder what's going on over there?

[Anonymous]

hi. I work for an insurer in pharmacy. just because it is off formulary doesn't mean you can't get it. 2 options. pay full price (but still get a discount) or appeal.
often you can get coverage with proof that other meds failed etc.

you can thank the endless amount of people over prescribing and over utilizing these meds for putting you in this position.

if they allow all the drugs the abuse and fraud in this class is insane. some controls for cost and overuse just have to be put in place sometimes. if your child really needs one particular drug and there is doctor and rx history, it should go through.

[Anonymous]

I should add, almost every insurer has a formulary where they add and take off certain drugs. this isn't something unique to UHC. the Medicaid and Medicare formularies are typically even leaner. and no, I don't work for UHC.

[Anonymous]

The list includes Daytrana, generic Focalin XR, Focalin XR, Intuniv, generic Metadate DC, generic Ritalin LA, generic Concerta, Quillivant XR, Ritalin LA, and Zenzedi. Whether your plan will continue coverage of these drugs depends on the plan you are on. According to what I've received, there is no appeal process. You are free to use whatever medication you want, but some or all of these may not be covered under my plan.

[Anonymous]

insurer employee person posting again. know that if they are blocking generic concerta, they may still be covering Concerta exclusively (the brand).

[Anonymous]

They stopped covering DC's asthma medicine this past January.

[Anonymous]

Anonymous wrote:hi. I work for an insurer in pharmacy. just because it is off formulary doesn't mean you can't get it. 2 options. pay full price (but still get a discount) or appeal.
often you can get coverage with proof that other meds failed etc.

you can thank the endless amount of people over prescribing and over utilizing these meds for putting you in this position.

if they allow all the drugs the abuse and fraud in this class is insane. some controls for cost and overuse just have to be put in place sometimes. if your child really needs one particular drug and there is doctor and rx history, it should go through.

This hasn't been my experience. I wrote in another thread that my insurance company refused to cover Strattera (non-habit forming and non-stimulant) before I tried Vyvanse (a stimulant). Why? Because Vyvanse was shown to be "more effective." All of these decisions by insurance companies are based on the bottom line, not out of any concern from abuse (though certainly it is the case that people abuse ADHD stimulant medications). Strattera would have been more expensive for them to cover, I am sure, both in terms of whatever cost from supplier as compared to Vyvanse and perhaps also additional appointments with my psychiatrist, since you need to check in more often at least in the beginning when you are slowly upping the med.

[Anonymous]

The decisions are made by teams of docs and pharmacists. They don't just make decisions based on costs and that's it. Again to the op, you can appeal or pay out of pocket.

[Anonymous]

Anonymous wrote:The decisions are made by teams of docs and pharmacists. They don't just make decisions based on costs and that's it. Again to the op, you can appeal or pay out of pocket.

The decision should be made b/w the child's doctor and the parent. Period.

[Anonymous]

Anonymous wrote:

Anonymous wrote:The decisions are made by teams of docs and pharmacists. They don't just make decisions based on costs and that's it. Again to the op, you can appeal or pay out of pocket.

The decision should be made b/w the child's doctor and the parent. Period.

The decision on what medication should be prescribed should be between the doctor and parent. But coverage is between the employer and the carrier. The employee and his/her family is the beneficiary of this benefit of employment. That being said, I feel for those who are in the position of deciding between paying out of pocket or changing meds.

[Anonymous]

right, it's an unfortunate situation when someone has to change. unfortunately not all doctors make good choices regarding prescribing. it would be a free for all without insurer and pharmacy and PBM guidelines. the best way to make sure members get appropriate and cost effective treatment is to have edits and policies in place. you will be hard pressed to find an insurer that just puts all of anything on a formulary.

the guidelines are made by medical professionals that form a committee and vote on decisions. these are upstanding professionals with no skin in the game, unlike your doctor sometimes unfortunately. they do understand though that wasting employer or fed dollars on inappropriate or ineffective treatment just hurts everyone else.