Expert: Tricia - 10/18/2005

Question
My teenage son has been diagnosed with a severe case of Attention Deficit Disorder (without the hyperactivity component) After many doctors, evaluations and prescriptions, we finally have found a specialist who, after complete and through evaluation and drug trials, has been able to help him.  My issue is this:  my son is prescribed two 56mg doses of concerta in the morning and another 56 mg dose after school.  The insurance company will not pay, saying that the Federal guidelines are for maximum 72 mg per day.  I went through two levels of complaints/appeals etc with the insurance company, had the docotrs office write letters etc but they still refuse to pay.   The medicine if $350 a month!  Any ideas how I can get them to pay?

Thank you for any help.

(we have UPMC Healthcare in Pennsylvania)


Answer
Hi!

Most insurance companies do regulate their payout of all prescriptions now....something they did not do to much in the years past.  If they state in your policy that they will not pay for a max of 72mg, then they do not have to...however it should be stated somewhere in your policy.
My insurance company, Aetna gives me a list each year on the drugs they will not pay at all and the limits of some others.......believe it or not, it is about 25 pages........
And I am sure they pick the ones that have the highest cost.

Concerta is suppose to be taken one daily......one tablet is suppose to last up to 12 hours so it is very unusual for a DR to prescribe your son to take 3 a day.......most children are on 36-54 mg once a day.......this is the norm and unforunately your insurance company is following that as their rule.

Be very cautious of giving to much to your son.......I know how frustrating this process is, my son had ADD also as a child......one of his DR's kept increasing his Ritalin dosage up and my son ended up very sick......

If your insurance refuses to pay, and they have the right not to pay what is not in terms with your policy, you have two choices........reduce your son's dosage down to the 72 mg per day, using perhaps the weekend dosage for the weekday, or go on line and find this drug cheaper such as sites like drugstore.com.........this drug is very expensive so you may reduce your cost some but it will still be very high........

I do understand what you are going through......good luck!

Tricia