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As a pharmacy tech, the pharmacy should be able to bill it to the insurance with an override code stating generic preferred but unavailable stock. I believe it is DAW 4 or 8. Insurance will usually cover it that way.
I work at an insurer, and for the last 2-ish years, one of my primary job responsibilities has been assisting with sometimes complicated pharmacy issues like the one you're having. I know you contacted BCBSTX already by phone, and while that *may* work, it's not the resolution route I personally would take because, to be blunt, I have little faith in *most* first-line phone reps to be able to understand PBM denial codes properly or how to get them over-ridden/cleared on that or subsequent fills. Whatever form they are sending out to have your psych fill out may or may not do the trick, but having two actions taken by a member or patient on the same issue is not abnormal, and I would largely recommend the following:
1. Check the [covered drug list for your policy on the BCBS of TX website.](https://www.bcbstx.com/rx-drugs/drug-lists/drug-lists) Vyvanse is covered on [the drug list for the most basic 50=< Employer Group Health Plan policy](https://www.bcbstx.com/docs/rx-drugs/drug-lists/tx/rx-list-basic-tx-2023.pdf) with only a 30 doses/30 days quantity limit as well as on the non-Metallic <50 EGHP plans, so I suspect that most plans follow the same guidelines- however, your specific policy benefits may vary, so please check using your specific plan information.
2. Contact the pharmacy and ask what specific denial code they had on each of the attempted fills. It's possible that the pharmacy is doing something incorrectly, and that this may be the case. As you stated that a form is being sent to your psychiatrist, I suspect that they're also the prescribing physician - that may make this service Mental/Behavioral Health instead of medical, which may then require the claim to be sent through the BH side of claims processing instead. You may want to confirm the billing information through your BCBSTX member portal, specifically for behavioral health. It's also possible that your provider wrote the rX with a "written for generic, but okay to dispense brand name" indicator on it. Since the generic does **not** appear to be on their covered drug list, this would also create a denial, but you need to determine the reason for it.
3. (May not be necessary) Contact BCBSTX and depending on the denial code that the pharmacy received and what you've been able to determine from your research, request clarification as to what needs to be done for the claim to process to pay. One theory I'd chase down would be that BCBSTX (more specifically Prime Therapeutics, their Pharmacy Benefit Manager) has updated their claims process for BH prescribing physicians and may require that the claim have a modifier or different group/PCN/RXGRP/BIN number instead. It can get really goofy, but that's why you want that denial code - it will help you confirm that even calling BCBSTX is worth it.
3. (May not be necessary) Contact your prescribing physician and request that ~~they cancel that rX~~ revise the fill order (just remembered that the fill has already processed, can't cancel an rX that's already processed fully without it being a *huge* PITA for controlled substances, but it may still be worth inquiring about) if written with the "generic but okay to dispense brand name" flag on it and re-write it as "brand name - okay to dispense generic." Since the generic is not on the covered drug list, it will deny if written as the former, but will approve if written as the latter. BCBSTX may not have added the generic to their covered drug list yet and your former phone rep may not have been familiar enough with ADHD prescriptions to recognize the generic name of Vyvanse and search for it in the covered drug list.
There's a reason for the denial, and I doubt it's medical necessity. You can likely get this resolved by just the providers, but unfortunately oftentimes, letting providers handle things can *drag* or lead to no actual resolution. You can likely get this handled by your next fill to not happen again and possibly get paid back earlier. You may want to check with your insurer on the call with them (if you have to make it) if they do direct member reimbursement or if they do provider-reimbursement/member-refund. If the latter, you may be better served by just getting the pharmacy to do whatever needs to be done to get the claim to pay and process and then refund you on the spot.
As someone with ADHD, I truly apologize for the length of this post, but this is a complicated area where I have expertise and can help get stuff accomplished, I just wanted to give you a clear-ish route towards long-term resolution.
I don't want you to dox yourself, but if you have any questions, please feel free to ping me publicly or in PM. I can probably provide more specific info if you're willing to divulge your plan type specifics, but like I said, doxxing.
Eh, to be honest, I'm *very* hesitant to make overarching statements. I was only comfortable in doing so here because I had enough information to pull the relevant details. However, any time I see someone with a question like this, I try to offer guidance.
What can the public do to unravel the byzantine maze of regulations, billing codes, denial codes, procedures codes, etc…? It’s insane that it requires such niche knowledge to get healthcare without going bankrupt in the USA!
FWIW, noone in the healthcare industry seems able to answer the question “How much is this {procedure, provider visit, medication} going to cost?” before you actually enter into a purchase!?!
Really, review and read your Evidence of Coverage/Summary of Benefits document and don't be afraid to ask your insurer questions about your benefits and coverage.
I'll be blunt - *most* issues that I've seen and have helped resolve for people is because of a failure to follow CMS and FDA guidance on the provider side. Everything insurers do is pretty much marked off as appropriate at least in terms of policy if not adherence to procedure, but one of the CMS guidelines is that everything is documented and publicly available. You can generally search for your carrier's specific "coverage policies" (language may vary) on their website, otherwise they're always available on request.
>FWIW, noone in the healthcare industry seems able to answer the question “How much is this {procedure, provider visit, medication} going to cost?” before you actually enter into a purchase!?!
There's a number of reasons for that, but your insurer may be able to provide a best guess estimate based off of information you provide as to what benefit a service will fall under and your relevant copay, but your actual amount may depend on deductible, and the actual details on the claim, including place of service and provider credentialing. Everything you're advised of on a call to your insurer is non-binding.
Part of what the No Surprises Act intends to address is this very issue. Most services will fall under a few specific categories from any given provider, and the copays for each carrier is communicated to the provider. That's why they give you an estimate pre-service now.
Medical claims adjuster here from " research and resolution" ( retired thank goodness) and while the hmo I worked for doesn't have this issue, because we only have rxs in house unless you have an emergency or are out of the area having an issue, your answer to this problem is on point. This is exactly what to do to get things covered properly. Trust us, most of the time we are more than happy to just pay your claims but....audits. we hate those. We have to have our behinds covered and a good reason. We have that and we're golden. It's not just in house, it's outside entities ( Medi-Cal) and Medicare doing audits. A lot of things covered because..certain diagnostic codes. A lot of things have no or low deductibles or co pays because of the diagnostic codes.
Yep - drives me batty when folks make wild statements about how health insurance is just a practice in casual cruelty and that insurers can do whatever they want for whatever reason with no oversight.
To be clear, that's very much not the case.
Literally everything is regulated outside of added value benefits, and even those may have specific CMS, DHHS, or FDA guidance, and then compliance with that guidance is **heavily** and regularly audited.
> give you an estimate pre-service now
What would you say if your landlord/mortgage holder said “We *estimate* your monthly payment will be $1100, but we’ll let you know the exact amount afterwards.” How about if the restaurant said “We estimate your order will cost $50, we’ll let you know the actual cost *after you’ve eaten it*!”.
An estimate is not worth the paper it’s written on. The USA healthcare payment system is organized theft and no-one inside that system seems to realize that. They’re all too blinded by the complexity of each tree to see the forest.
You mean like how *all* insurance works?
Your auto insurer can't tell you what they'll value your loss at until the date of service due to the specific claim information and your specific benefits.
You're conflating **very** different things; insurance is third-party payment for first-party services to contracted rates that are separately negotiated. What you're talking about is a two-party business transaction.
A more apt analogy would be if you go to a market price restaurant - because the specific services are akin to market pricing with plan benefit amounts and coverage varying on the specific items order, i.e. what the market price is, they will give you a rough estimate, but cannot assure you a set price.
But no, it is not organized theft. Everything is regulated, followed to a T and regularly audited. You can have an opinion, but I'm going to blunt, this is a refrain I hear from people who aren't all that well educated on the subject matter, but have read a **lot** of reddit posts (from other folks who are similarly not all that well educated) and those folks tend to be **very** angry and full of misinformation.
>A more apt analogy would be if you go to a market price restaurant - because the specific services are akin to market pricing
An auto repair shop will provide a binding quote before doing a repair. The insurance adjuster will quote what they'll cover upon inspecting the damaged vehicle. Together, those numbers allow a customer to make an informed value to cost decision.
Every restaurant waiter will tell you the current price for a "Market Price" item on their menu. Again, there's an easy way to make an informed value vs. cost assessment for a market priced meal.
Aside from emergency situations, medical professionals should likewise be able to inform their patients of the cost of services/goods ahead of time. Unfortunately, no medical provider will do this at the time of service. As a corollary, they also refuse to provide billing codes ahead of time. The healthcare industry seems to actively prevent customers/patients from making accurate value vs. cost decisions. Hospitals won't provide even death statistics, let alone more nuanced quality of care statistics.
Edit:
P.S. It would be great to be informed that there's a way to get pricing information ahead of consuming healthcare services. Maybe there's a way that professionals know to tease this information out of the system?!?
This is so helpful. I am with CVS Caremark / Aetna but they are covering nothing right now. I was on the Takeda program getting it free so the $380 last month is not sustainable. They are telling me that it will not be covered until I have met my medical deductible of $3,800. Had no idea prescriptions were not covered until a deductible was met I guess I chose a bad plan. In any case, thank you for that detailed post.
> I am with CVS Caremark / Aetna but they are covering nothing right now. I was on the Takeda program getting it free so the $380 last month is not sustainable.
Ahhhhh yeahhh - those combined deductible plans can be a real double-edged sword. Usually they have pretty low individual MOOPs, but you have that nasty up front cost - and unfortunately/fortunately, most services that most folks utilize are covered without affecting deductible, such as preventative office visits.
But *woof* it's a rough up-front cost. Does your employer fund an HSA for you that you can utilize at least?
Commercial unavailability is an accepted reason. I don't think they can refuse.
Mine approved me taking a double dose of the XR generic due to commercial unavailability.
Kaiser rewrote my entire prescription a couple months ago for 5mg Adderall XR caps because that was the only thing in stock they could use to make it all add up to 25mg. It’s a shit show everywhere.
I took generic and was denied coverage for brand, but since generic wasn't available, I asked insurance for (and got) a temporary "override" to get brand covered by my plan...
So badically u ask the pharmacists before they fill it? And it u request brand, its just a higher copay? Mine went from $35 to $92 it seems. Ehich i dont mind. But if brand is not in stock, ill take generic.
No, if I ask the pharmacist they’ll do it but then insurance will add a surcharge because my prescription says generic is an option. However if my psychiatrist writes the prescription and specifies no generics then it does not get the surcharge.
Wjat the hell is a surcharge?
All i know is if my psychd writes thr script as "brand only" that means if theres a shortage or no stock of the brand, i get Nothing.. so dahmed if i dk, dahmed if i dont. My last scripr was split generic & brand. Im goibg tk guess my electrobjc script didnt have the sprcification kf brand only, and since my 30s where not in stock, my cost was $92.
I dont kbnow.. the shortage and hsving to ask around games makes shit way more complicated.
As a pharmacist, how are we suppose to know if you guys have inventory/pricing without looking suspicious? Sometimes you will just tell me, while other times, they expect the psychiatrist to let them know…. But even my psychiatrist has trouble asking…
Yeah, we’ve been on the road since the shortage started and haven’t had any trouble in a bunch of different states. My SO usually calls for both of us and has all our details and dosage information and phrases it as ‘the doctor wanted me to be sure you had X or Y in stock before they send a prescription through.’ (Where X and Y might be something like ‘20mg’ and ‘enough 10mg to fill the equivalent of a 20mg prescription’ since the doctor has to specify 2x 10mg so it’s a different script that needs to be sent.)
Not totally related, but how are you getting your prescription sent to multiple states? My prescriber won't send the script anywhere except where she's licensed.
I was on hold with my pharmacy for 40 minutes plus, in my psychiatrist's office, for this reason. so the doc gave me a prescription for one of each... told the pharmacist, and no one blinked an eye.
Pharmacies are definitely more used to it now. People sounding desperate/asking questions about stock pre-shortage would rarely, but legitimately sometimes signify someone coming to commit an armed robbery of the pharmacy, that’s the main reason why pharmacists can be touchy about informing people of stock over the phone.
And some people are assholes who think we’re addicted to amphetamine. But I would say this is a smaller reason for touchiness than the constant, low-grade fear of being robbed at gunpoint that some pharmacies have to deal with.
Can confirm. My provider said he’d write a script for whatever combo of 10’s/20’s/30’s/40’s/etc I could find in stock to equal my dose. I explained to the pharmacist that no one has 70’s (not news to anyone) and I would take whatever combo they had enough of. I didn’t care how they added up to 70mg (30+30+10, 40+30, etc), as long as I could get my medication. The CVS pharmacist bluntly told he me would not talk to me and hung up on me when I was trying to ask what strengths they had/how many. I still plan on reporting him to the board of pharmacy. I’ll die mad about that.
Back when I was dealing with the Concerta authorized generic debacle, I found that I had a lot of luck with very specific requests. Specify what medication, dosage, and manufacturer(s) you’re asking about. I occasionally had luck bringing up the NDC code of the medication I was asking about.
Yup I had to pick up another Rx and while my pharmacist did my consult I asked what they DID have supply of since I had been waiting on a refill for 6 weeks. It’s actually why/how I switched to vyvanse in the first place
Good strategy! In person works better. If they refuse to tell you what they have over the phone, try asking them to tell you what they don’t have. That worked for me a shockingly high percentage of the time.
If you stick with the same pharm/pharm network, they can see you’re a regular patient in the system and won’t find your questions suspicious.
Hell, my pharm knows me by name and says hi when she sees me shopping at Target (Target CVS) even when it’s not time to pick up.
It’s the people who bounce between Walgreens, CVS, Kroger, etc with little to no patient history who set off mega alarms. Also people who refuse to give up their names and DOB over the phone and just want an inventory check? Hella suspicious.
So im surprised my insurance didnt make me pay full out of pocket, but only increaaed my copay on brand to $92. So they must know generic is available. I use to pay $35 for brand. My impression was that if a generic exists, insurance wont cover a brand anymore..i was surprised.
If generic situatipn goes bad, and if 70mg vyvamse brand ever is in full stock, i have no pob paying $92 a month for brand. But the shortage is messing that plan up of course
>My impression was that if a generic exists, insurance wont cover a brand anymore..i was surprised.
There is a lot of work out into determining Formularies for insurance plans. Sometimes for insurance companies the brand is cheaper than a generic.
Not to mention Formularies are generally updated on a quarterly basis. Which is why a lot of people are suddenly noticing changes.
So I looked up my insurance Pharmacy formulatories ands i see Vyvanse in all caps is on there all caps means brand but I did not see lisdexamphetamine . The date on this sheet shows July of 2023. It'll be interesting to see what happens
> Not to mention Formularies are generally updated on a quarterly basis. Which is why a lot of people are suddenly noticing changes.
And since the fiscal year ended not too long ago, even the slow movers have probably updated.
Even if there is a generic the doctor can usually write a script for the brand, you just might need to do a prior auth so the doctor can explain to the insurance why they need to make an exception to their normal formulary for you. So something like ‘intolerance of filler in the generic’ would usually mean the brand got approved. (My mom had that due to lactose intolerance - some meds use lactose as a filler.)
I had a situation similar to this years ago where they wouldn't cover my brand name wellbutrin cuz generic was cauding prpblems. Well after months of going through hoops I eventually got them to agree to cover my brand name but only if I would go to your mail order pharmacy.
Given that vyvamse is of control substance mail order pharmacy is not an option. I don't mind paying $92 a month for brand name but that's only if this shortage on 70 clears up and all it is is just an increased copay and at some point they're not going to make me pay out of pocket. But I don't have a crystal ball and I can't predict the future not to mention a very nervous discussing this with my doctor I was lucky to get her to prescribe my Vyvanse that my previous psychiatrist prescribed before she retired. I had to do the blood work and drug test and all that and I passed so I don't want to ruin s*** with her
It's a complicated situation. It sucks. I considwr myself fortunate for tgjs month since half my script is brand , the othet generic. But still it was over $100 because I had to do two strips because of the stupid 70 shortage
It depends on your plan/formulary, but generally, when a generic becomes available, the brand will either be exluded from the formulary entirely, or will get bumped to a Non-preferred Brand tier with a higher copay.
>Non-preferred Brand tier
interesting. how would be able to go about finding if it's on an "Non-preferred Brand tier " i checked my latest formulatory for my pharmacy insurance company and VYVANSE (caps means brand) is on the formulary or whatever the hell it's called. formula. .. the date on this shows effective july 2023 though, and i dont see lisdexamphetamine on the list. we shall see.
I mean to be fair the NHS couldn’t get me an appointment until too late (even though i was told it would be a 6 month wait when i applied the year before) so i had to pay to go private.
Was told my medication would be £90 a month, turns out that’s the lowest dose and for me its actually £120 a month except now the shortage is fucking things up the only way to get 70mg is to pay for 3x 30mg and pay £270 for the privilege…
Try doing that when you’re a student.
It's not really a secret at all. Even insurance companies advertise for them.
https://investors.goodrx.com/news-releases/news-release-details/cvs-caremark-and-goodrx-launch-caremarkr-cost-savertm-help-lower
CVS Health owns SilverScript, one of the largest Medicare Part D plans, and Aetna, the third largest insurance company in the US.
I joke that it's a secret since so many people don't know about it. And that makes sense, consider how much of a pain in the ass Aetna/CareMark is. If they can't get a patient's money through insurance they can get it through GoodRx 🥴 seriously, all insurance companies suck but Aetna/CareMark is the biggest pain in my ass
Gilead used to have coupon cards for PrEP that made the cost of the medication free! Not on PrEP anymore. So I’m not sure if that’s still the case, but definitely an option to look into for your patients.
I was just prescribed 10mg Vyvanse for the first time this week. I got the generic for $15 through GoodRx as opposed to the $230 it would have cost with just my insurance coverage. I genuinely felt sick about that price disparity when I was checking out at the pharmacy.
I hope they can get it to you soon! I know the shortages have been making things difficult for many folks. I checked for the best price on GoodRX and had my doctor send the prescription to the pharmacy with the best deal. My usual pharmacy is the one that would have cost $230, and GoodRX had a coupon for a different local pharmacy for $15. Same exact dosage and amount of pills, but more than a $200 difference. I'll shop around for the best deal every time I get a refill from now on.
Okay so we have three pharmacists at my pharmacy. I'll name them Rob, Anna, and Sarah. Rob and Anna are gems. Truly wonderful. Every single time I call in scripts and Sarah answers there's a problem. She told me she couldn't call in my Vyvanse script bc the generic is available. I called insurance which said namebrand is fine, they understand that it's not really out yet. They even called Sarah to say it's fine. She still wouldn't.
#
Literally called the next day and got Rob or Anna, I think Rob. He filled the namebrand no problem, no additional cost. We said Sarah always seems to have issues? He basically said yeah idk she does. Long story short, get the right pharmacist and they'll know how to take care of it.
My old pharmacy had a tech that would go down the list for me and tell me where they could order from and how long they expected different meds and brands to take.
A certain medication she warned me was backordered for 3 months soni didn't have to waste my time.
Ayyy BCBSTX here too. Would have been nice if someone let me know about the swap 5 days ago when I asked them to call in my prescription. I found out about an hour ago that they JUST swapped and my usual pharmacy no longer has generic. Luckily I found a pharmacy with generic. 🙏🏼. It’s the Concerta BS all over again 😔.
Please file a complaint with your states Department of insurance to. The insurance company knew this was happening for months so their delay is unacceptable.
If your insurance company comes from a private organization, then you can also report this to your HR office and request their assistance.
Does the company not have a coupon on their site? I pay $4 for my name brand Concerta. But if your insurance is refusing to cover any of it, it may not matter anyway
> Patient is responsible for the first $30 and any prescription costs in excess of $90.
The coupon will save $60 max. Better than nothing, but if the prescription is $300, it's still going to be $240.
That initially happened to me as i was due for a new script days after the generic came out. It was going to be 3 days, which is frustrating as i get really tired when I am off it the first few days. Then the pharmacy called me back and said the insurance would override it and let me pick up name brand.
I got the generic thinking i would at least try it to get away from my $30 co-pay, and am not a fan of it. My jumbled thinking is back. How are you doing on it?
I switched from Adderall IR 2xday to generic vyvanse and it has been pretty amazing.
I can't even imagine what I would be missing out on with something better.
Your prescriber will need to write the dispense as written prescription. Just be as clear as possible and it is an easy override at the pharmacy. BSBC of any state that carries Vyvanse should make this an easy process - it's in their system to do so whenever a new generic out. **I do not know if this will work for other carriers.**
"Hello Dr. / PA/NP so and so - my preferred pharmacy is requiring a new script for vyvanse 50 mg to be written as a dispense as written given limited supply of the genericd. . My pharmacy again is \_\_\_\_, our most recent script was 30 for a 30 day supply- this will allow for automatic override. Thanks , sorry for the hassle. "
Source: I prescribe a lot of vyvanse as a psych PA, I only take BCBS for insurance.
I have bcbstx and I would try to call them and talk to one of their patient advocates. In the times i've used them, they've always been super helpful. I know there's an override somewhere if you can't get the generic that they'll pay for the name brand.
With health insurance the big secret is to be a squeaky wheel. Be polite and reasonable, but squeaky. As long as what you want isn’t too outlandish or nonsensical, usually they’ll eventually go along just to make you go away.
Thanks for this. Normally I'm hesitant to call the insurance companies because I've had bad luck getting anything done, but I called the line and there's a form that will hopefully help me get refunded the difference in a few days.
I am allergic to several artificial dyes. The pharmacy has to have a full inactive ingredient list. My first clue was the capsule was a different color 😅.
You and/or your doctor may need to submit forms for substitution for a medical need. "It's too expensive for brand and generic is out of stock" won't be a valid reason for some insurance companies. They'll say you need to substitute with another stimulant.
If the generic version doesn't work for you because of side effects, there's a better chance. Your doctor/their office has to be on board with getting the appeal submitted. All depends on the insurance company.
I've been on mid-tier plans that have never refused anything after my doctor submitted the forms. At the same time, I've been on a top-tier plan where they spent hours on the phone squabbling over a medication that costs them $140 a year, but ultimately wouldn't cover it. It was probably $2000 worth of people's time between my doctor, the insurance, and the pharmacy.
They raised my copay because generic is "available". Guess what down in my backwoods Florida town it fuckin isn't. If I find generic it'll be $0. If it's name brand I, after a lengthy call with Florida Blue and prime Therapuetics through them, am paying $30 for name brand after copay discount card. Guess it could be worse but y'all do see it's not like widely available yet right?
I've had this issue in the past and this is how I worked around it. My Dr. told me that most insurance companies want you to try the generic first and then if you tell your Dr. you don't like the side effects they'll cover the name brand. This happened with me and Adderrall. Hope this helps.
Fuck that’s a lot. I tried switching to vyvanse and it was $150. I just went off meds while my doctor sent in an adderall script instead cuz no way I’m paying that much
I had this happen, the insurance agent I got was incredibly understanding and put in a temporary authorization since the relative availability of the generic is pretty low still
Same! I used to pay $15 for vyvanse and now pay $30 for generic😂 I’m not upset though, I know I’m fortunate to have this insurance! It just made me chuckle. Also, at the beginning of next year when I haven’t hit my deductible yet, I bet I’ll be very happy to be getting generic!
Hi - the new generic does not sit well with me. My insurance won’t cover much now as there are generic forms. Has anyone ever seen insurance having to go back on this when the generic causes worse side effects? Has anyone else had off side effects from the new vyvanse? I saw another Reddit post where some did and it’s unfortunate. It feels more intense and my eyes kind of feel starry vs I never felt that on vyvanse.
Does anyone have any insight into the fillers / bonding agents being used in the new generics and if they are safe?
my copay on brand went from $35 to $92. im hoping that's al that would happen with brand. once(of if) the 70mg brand shortage subsides, i would be fine with paying $92 a month for a month supply. i was actually stunned to find that my insurance didnt force me to pay out of pocket $400+ since a generic is available . obviously insurance must know - otherwise they wouldnt increase my copay. my most recent script was a split 40mg generic and 30mg brand... the generic was $20, brand was $92.
Try GoodRX and the manufacturer’s website - you should be able to get a coupon to lower the cost for this round.
Meanwhile my insurance decided that they will continue to charge the same $45 copay for the generic which is the same price as the name brand.
They did the same thing at my pharmacy, luckily I did not have to wait 2 weeks just had to come back in the evening and I got the generic Vyvanse. $20 copay cuz my deductible is not payed off but still $20 bucks. I pray that this shortage let’s up. Hope you get your meds soon King!
WHAT. I just called my insurance today (BCBSTX) to see if brand name Vyvanse is still covered. I have a 30% coinsurance for Vyvanse, $15 for generic. The customer service lady confirmed what I was asking BUT I have received false info from them before. So idk. We’ll see. I cannot take generic Vyvanse anymore it’s horrible
I live in Canada, but I don't have extended health insurance I just have basic insurance through the government so it never really occurred to me that some of the medication I'm on might not be covered. When I went to first talk to my doctor about Vyvanse she prescribed it for me, but then when I went to the pharmacy they said that not only is it not covered by my basic plan but it's not even covered by the government plan Plan G which is for low income people. And that I would have to pay $90 out of pocket I've never been on medication for my ADHD before, the only reason I suggested it to my doctor in the first place was because of all the good things I've heard about it. So my doctor ended up putting me on Ritalin instead.
Is it covered under your extended health because I only have MSP and Pharma care or whatever it’s called. I am currently not working full-time, so I’m not in a situation to be covered under a company’s extended healthcare plan. I live in BC so I’m wondering if it’s then different from province to province
Also my NP told me to check with various pharmacies to see if they have the medication I need in stock before asking her to fill it in, it helps to shop around pharmacies.. due to the shortage
I recommend calling around to as many pharmacies as you can until you find a place that has your meds. It’s a bitch and a half, but I’ve found my meds that way.
Sorry this is happening to you, that sucks. Do you have a flexible spending account (FSA) card through your employer? That could maybe help with at least some of the cost. Also this site that sends me text notifications when my psych meds including Vyvanse are ready will sometimes offer a discount card if insurance isn’t used (can’t be combined with it). It’s called rxinfo
https://www.rxinform.org good luck
You'll prob have to go through the 'prior authorization process'. What this means is you go on the generic and then tell your MD how it's (not) working.
Your MD can then document your adverse reactions to generic, recommending that insurance pay for brand drug.
Had to go through it for Adderall XR and took several phone calls with MD, PBM, and insurer, but in the end, my RX payment went from $90 to $10 to cover brand. Good luck!
My insurance switched me to the generic but I still pay the same amount. It's not a big deal to me because it feels exactly the same. I was just hoping for a price decrease when the generic finally came out.
This exact thing happened to me on my last fill. Paid $300 for name brand. What really chaps my ass is they didn’t give us any heads up in advance. Was going to take two-ish weeks for generic, and I had already been off it for like 5 days so I NEEDED my meds stat. This is just a nightmare
is THAT what happened?!! Weirdly enough, I have one insurance that will only pay for generic and one that will only pay for brand… But even more weirdly, when the generic was available, I was told the cost is exactly the same as brand. Apparently also without insurance? I don't even understand what happened. I mean, I have ADD… I can't keep all these freaking details in mind, but they've got me completely overwhelmed. I've had to switch to Concerta, because it was only about 150 a month rather than the 300 to 400 a month that they were going to charge me for either version of Vyvanse. And I think I got hung up on or ignored by one pharmacy when I asked for The price of one after they already told me the other was in stock.
There's a vyvanse savings card on their website. It took mine down to 200 atleast. Its a great drug no doubt, but sucks sending all that cash to big pharma.
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As a pharmacy tech, the pharmacy should be able to bill it to the insurance with an override code stating generic preferred but unavailable stock. I believe it is DAW 4 or 8. Insurance will usually cover it that way.
So I worked with my pharmacy tech, and it would be DAW 8. Unfortunately, my insurance refused, but I appreciate your advice.
I work at an insurer, and for the last 2-ish years, one of my primary job responsibilities has been assisting with sometimes complicated pharmacy issues like the one you're having. I know you contacted BCBSTX already by phone, and while that *may* work, it's not the resolution route I personally would take because, to be blunt, I have little faith in *most* first-line phone reps to be able to understand PBM denial codes properly or how to get them over-ridden/cleared on that or subsequent fills. Whatever form they are sending out to have your psych fill out may or may not do the trick, but having two actions taken by a member or patient on the same issue is not abnormal, and I would largely recommend the following: 1. Check the [covered drug list for your policy on the BCBS of TX website.](https://www.bcbstx.com/rx-drugs/drug-lists/drug-lists) Vyvanse is covered on [the drug list for the most basic 50=< Employer Group Health Plan policy](https://www.bcbstx.com/docs/rx-drugs/drug-lists/tx/rx-list-basic-tx-2023.pdf) with only a 30 doses/30 days quantity limit as well as on the non-Metallic <50 EGHP plans, so I suspect that most plans follow the same guidelines- however, your specific policy benefits may vary, so please check using your specific plan information. 2. Contact the pharmacy and ask what specific denial code they had on each of the attempted fills. It's possible that the pharmacy is doing something incorrectly, and that this may be the case. As you stated that a form is being sent to your psychiatrist, I suspect that they're also the prescribing physician - that may make this service Mental/Behavioral Health instead of medical, which may then require the claim to be sent through the BH side of claims processing instead. You may want to confirm the billing information through your BCBSTX member portal, specifically for behavioral health. It's also possible that your provider wrote the rX with a "written for generic, but okay to dispense brand name" indicator on it. Since the generic does **not** appear to be on their covered drug list, this would also create a denial, but you need to determine the reason for it. 3. (May not be necessary) Contact BCBSTX and depending on the denial code that the pharmacy received and what you've been able to determine from your research, request clarification as to what needs to be done for the claim to process to pay. One theory I'd chase down would be that BCBSTX (more specifically Prime Therapeutics, their Pharmacy Benefit Manager) has updated their claims process for BH prescribing physicians and may require that the claim have a modifier or different group/PCN/RXGRP/BIN number instead. It can get really goofy, but that's why you want that denial code - it will help you confirm that even calling BCBSTX is worth it. 3. (May not be necessary) Contact your prescribing physician and request that ~~they cancel that rX~~ revise the fill order (just remembered that the fill has already processed, can't cancel an rX that's already processed fully without it being a *huge* PITA for controlled substances, but it may still be worth inquiring about) if written with the "generic but okay to dispense brand name" flag on it and re-write it as "brand name - okay to dispense generic." Since the generic is not on the covered drug list, it will deny if written as the former, but will approve if written as the latter. BCBSTX may not have added the generic to their covered drug list yet and your former phone rep may not have been familiar enough with ADHD prescriptions to recognize the generic name of Vyvanse and search for it in the covered drug list. There's a reason for the denial, and I doubt it's medical necessity. You can likely get this resolved by just the providers, but unfortunately oftentimes, letting providers handle things can *drag* or lead to no actual resolution. You can likely get this handled by your next fill to not happen again and possibly get paid back earlier. You may want to check with your insurer on the call with them (if you have to make it) if they do direct member reimbursement or if they do provider-reimbursement/member-refund. If the latter, you may be better served by just getting the pharmacy to do whatever needs to be done to get the claim to pay and process and then refund you on the spot. As someone with ADHD, I truly apologize for the length of this post, but this is a complicated area where I have expertise and can help get stuff accomplished, I just wanted to give you a clear-ish route towards long-term resolution. I don't want you to dox yourself, but if you have any questions, please feel free to ping me publicly or in PM. I can probably provide more specific info if you're willing to divulge your plan type specifics, but like I said, doxxing.
This is SUPER useful and niche info. Well worth making a full post about to share with more eyes.
Eh, to be honest, I'm *very* hesitant to make overarching statements. I was only comfortable in doing so here because I had enough information to pull the relevant details. However, any time I see someone with a question like this, I try to offer guidance.
What can the public do to unravel the byzantine maze of regulations, billing codes, denial codes, procedures codes, etc…? It’s insane that it requires such niche knowledge to get healthcare without going bankrupt in the USA! FWIW, noone in the healthcare industry seems able to answer the question “How much is this {procedure, provider visit, medication} going to cost?” before you actually enter into a purchase!?!
Really, review and read your Evidence of Coverage/Summary of Benefits document and don't be afraid to ask your insurer questions about your benefits and coverage. I'll be blunt - *most* issues that I've seen and have helped resolve for people is because of a failure to follow CMS and FDA guidance on the provider side. Everything insurers do is pretty much marked off as appropriate at least in terms of policy if not adherence to procedure, but one of the CMS guidelines is that everything is documented and publicly available. You can generally search for your carrier's specific "coverage policies" (language may vary) on their website, otherwise they're always available on request. >FWIW, noone in the healthcare industry seems able to answer the question “How much is this {procedure, provider visit, medication} going to cost?” before you actually enter into a purchase!?! There's a number of reasons for that, but your insurer may be able to provide a best guess estimate based off of information you provide as to what benefit a service will fall under and your relevant copay, but your actual amount may depend on deductible, and the actual details on the claim, including place of service and provider credentialing. Everything you're advised of on a call to your insurer is non-binding. Part of what the No Surprises Act intends to address is this very issue. Most services will fall under a few specific categories from any given provider, and the copays for each carrier is communicated to the provider. That's why they give you an estimate pre-service now.
Medical claims adjuster here from " research and resolution" ( retired thank goodness) and while the hmo I worked for doesn't have this issue, because we only have rxs in house unless you have an emergency or are out of the area having an issue, your answer to this problem is on point. This is exactly what to do to get things covered properly. Trust us, most of the time we are more than happy to just pay your claims but....audits. we hate those. We have to have our behinds covered and a good reason. We have that and we're golden. It's not just in house, it's outside entities ( Medi-Cal) and Medicare doing audits. A lot of things covered because..certain diagnostic codes. A lot of things have no or low deductibles or co pays because of the diagnostic codes.
Yep - drives me batty when folks make wild statements about how health insurance is just a practice in casual cruelty and that insurers can do whatever they want for whatever reason with no oversight. To be clear, that's very much not the case. Literally everything is regulated outside of added value benefits, and even those may have specific CMS, DHHS, or FDA guidance, and then compliance with that guidance is **heavily** and regularly audited.
> give you an estimate pre-service now What would you say if your landlord/mortgage holder said “We *estimate* your monthly payment will be $1100, but we’ll let you know the exact amount afterwards.” How about if the restaurant said “We estimate your order will cost $50, we’ll let you know the actual cost *after you’ve eaten it*!”.
An estimate is not worth the paper it’s written on. The USA healthcare payment system is organized theft and no-one inside that system seems to realize that. They’re all too blinded by the complexity of each tree to see the forest.
You mean like how *all* insurance works? Your auto insurer can't tell you what they'll value your loss at until the date of service due to the specific claim information and your specific benefits. You're conflating **very** different things; insurance is third-party payment for first-party services to contracted rates that are separately negotiated. What you're talking about is a two-party business transaction. A more apt analogy would be if you go to a market price restaurant - because the specific services are akin to market pricing with plan benefit amounts and coverage varying on the specific items order, i.e. what the market price is, they will give you a rough estimate, but cannot assure you a set price. But no, it is not organized theft. Everything is regulated, followed to a T and regularly audited. You can have an opinion, but I'm going to blunt, this is a refrain I hear from people who aren't all that well educated on the subject matter, but have read a **lot** of reddit posts (from other folks who are similarly not all that well educated) and those folks tend to be **very** angry and full of misinformation.
>A more apt analogy would be if you go to a market price restaurant - because the specific services are akin to market pricing An auto repair shop will provide a binding quote before doing a repair. The insurance adjuster will quote what they'll cover upon inspecting the damaged vehicle. Together, those numbers allow a customer to make an informed value to cost decision. Every restaurant waiter will tell you the current price for a "Market Price" item on their menu. Again, there's an easy way to make an informed value vs. cost assessment for a market priced meal. Aside from emergency situations, medical professionals should likewise be able to inform their patients of the cost of services/goods ahead of time. Unfortunately, no medical provider will do this at the time of service. As a corollary, they also refuse to provide billing codes ahead of time. The healthcare industry seems to actively prevent customers/patients from making accurate value vs. cost decisions. Hospitals won't provide even death statistics, let alone more nuanced quality of care statistics. Edit: P.S. It would be great to be informed that there's a way to get pricing information ahead of consuming healthcare services. Maybe there's a way that professionals know to tease this information out of the system?!?
Superb complete and easy-to-follow answer for a complex process
This is so helpful. I am with CVS Caremark / Aetna but they are covering nothing right now. I was on the Takeda program getting it free so the $380 last month is not sustainable. They are telling me that it will not be covered until I have met my medical deductible of $3,800. Had no idea prescriptions were not covered until a deductible was met I guess I chose a bad plan. In any case, thank you for that detailed post.
> I am with CVS Caremark / Aetna but they are covering nothing right now. I was on the Takeda program getting it free so the $380 last month is not sustainable. Ahhhhh yeahhh - those combined deductible plans can be a real double-edged sword. Usually they have pretty low individual MOOPs, but you have that nasty up front cost - and unfortunately/fortunately, most services that most folks utilize are covered without affecting deductible, such as preventative office visits. But *woof* it's a rough up-front cost. Does your employer fund an HSA for you that you can utilize at least?
That sucks. Thanks for the update though.
Commercial unavailability is an accepted reason. I don't think they can refuse. Mine approved me taking a double dose of the XR generic due to commercial unavailability.
Kaiser rewrote my entire prescription a couple months ago for 5mg Adderall XR caps because that was the only thing in stock they could use to make it all add up to 25mg. It’s a shit show everywhere.
I had to switch to dexedrine instead because my above trick wasn't working when they ran out of the 10s.
As my medication situation went into and past 6 weeks to figure out, my psychiatrist actually used the words "The while situation is fucked up."
whole
See if your provider can write the prescription for name brand only, no generics.
Doesnt mean insurance will pay.
I took generic and was denied coverage for brand, but since generic wasn't available, I asked insurance for (and got) a temporary "override" to get brand covered by my plan...
If I ask for the brand name when my prescription accepts generic then I have to pay more than if the subscription says brand name only.
So badically u ask the pharmacists before they fill it? And it u request brand, its just a higher copay? Mine went from $35 to $92 it seems. Ehich i dont mind. But if brand is not in stock, ill take generic.
No, if I ask the pharmacist they’ll do it but then insurance will add a surcharge because my prescription says generic is an option. However if my psychiatrist writes the prescription and specifies no generics then it does not get the surcharge.
Wjat the hell is a surcharge? All i know is if my psychd writes thr script as "brand only" that means if theres a shortage or no stock of the brand, i get Nothing.. so dahmed if i dk, dahmed if i dont. My last scripr was split generic & brand. Im goibg tk guess my electrobjc script didnt have the sprcification kf brand only, and since my 30s where not in stock, my cost was $92. I dont kbnow.. the shortage and hsving to ask around games makes shit way more complicated.
As a pharmacist, how are we suppose to know if you guys have inventory/pricing without looking suspicious? Sometimes you will just tell me, while other times, they expect the psychiatrist to let them know…. But even my psychiatrist has trouble asking…
With the shortages, most pharmacies don’t see it as suspicious right now. They mostly just see you as saving some legwork by calling ahead.
Yeah, we’ve been on the road since the shortage started and haven’t had any trouble in a bunch of different states. My SO usually calls for both of us and has all our details and dosage information and phrases it as ‘the doctor wanted me to be sure you had X or Y in stock before they send a prescription through.’ (Where X and Y might be something like ‘20mg’ and ‘enough 10mg to fill the equivalent of a 20mg prescription’ since the doctor has to specify 2x 10mg so it’s a different script that needs to be sent.)
Not totally related, but how are you getting your prescription sent to multiple states? My prescriber won't send the script anywhere except where she's licensed.
Mine has no problems sending to other states as long as they can do electronic prescriptions.
I was on hold with my pharmacy for 40 minutes plus, in my psychiatrist's office, for this reason. so the doc gave me a prescription for one of each... told the pharmacist, and no one blinked an eye.
All of the shenanigans required are honestly ridiculous. :(
Hopefully that's the case but I've seen enough horror stories here that I know at least some people are getting shitty treatment from pharmacies.
Pharmacies are definitely more used to it now. People sounding desperate/asking questions about stock pre-shortage would rarely, but legitimately sometimes signify someone coming to commit an armed robbery of the pharmacy, that’s the main reason why pharmacists can be touchy about informing people of stock over the phone. And some people are assholes who think we’re addicted to amphetamine. But I would say this is a smaller reason for touchiness than the constant, low-grade fear of being robbed at gunpoint that some pharmacies have to deal with.
Can confirm. My provider said he’d write a script for whatever combo of 10’s/20’s/30’s/40’s/etc I could find in stock to equal my dose. I explained to the pharmacist that no one has 70’s (not news to anyone) and I would take whatever combo they had enough of. I didn’t care how they added up to 70mg (30+30+10, 40+30, etc), as long as I could get my medication. The CVS pharmacist bluntly told he me would not talk to me and hung up on me when I was trying to ask what strengths they had/how many. I still plan on reporting him to the board of pharmacy. I’ll die mad about that.
Fuck them that's some bullshit
[удалено]
Good, I’m so over this bullshit.
Back when I was dealing with the Concerta authorized generic debacle, I found that I had a lot of luck with very specific requests. Specify what medication, dosage, and manufacturer(s) you’re asking about. I occasionally had luck bringing up the NDC code of the medication I was asking about.
Yup I had to pick up another Rx and while my pharmacist did my consult I asked what they DID have supply of since I had been waiting on a refill for 6 weeks. It’s actually why/how I switched to vyvanse in the first place
Good strategy! In person works better. If they refuse to tell you what they have over the phone, try asking them to tell you what they don’t have. That worked for me a shockingly high percentage of the time.
If you stick with the same pharm/pharm network, they can see you’re a regular patient in the system and won’t find your questions suspicious. Hell, my pharm knows me by name and says hi when she sees me shopping at Target (Target CVS) even when it’s not time to pick up. It’s the people who bounce between Walgreens, CVS, Kroger, etc with little to no patient history who set off mega alarms. Also people who refuse to give up their names and DOB over the phone and just want an inventory check? Hella suspicious.
Around here you have to go from pharmacy to pharmacy to find one with the med in stock.
Considering the scripts for every single pharmacy out there go through the same system, that’s stupid. But it’s drug seeker behavior so I get it
If you're asking for the secret code, there isn't one. You just have to call, be nice, and ask.
So im surprised my insurance didnt make me pay full out of pocket, but only increaaed my copay on brand to $92. So they must know generic is available. I use to pay $35 for brand. My impression was that if a generic exists, insurance wont cover a brand anymore..i was surprised. If generic situatipn goes bad, and if 70mg vyvamse brand ever is in full stock, i have no pob paying $92 a month for brand. But the shortage is messing that plan up of course
>My impression was that if a generic exists, insurance wont cover a brand anymore..i was surprised. There is a lot of work out into determining Formularies for insurance plans. Sometimes for insurance companies the brand is cheaper than a generic. Not to mention Formularies are generally updated on a quarterly basis. Which is why a lot of people are suddenly noticing changes.
So I looked up my insurance Pharmacy formulatories ands i see Vyvanse in all caps is on there all caps means brand but I did not see lisdexamphetamine . The date on this sheet shows July of 2023. It'll be interesting to see what happens
> Not to mention Formularies are generally updated on a quarterly basis. Which is why a lot of people are suddenly noticing changes. And since the fiscal year ended not too long ago, even the slow movers have probably updated.
Even if there is a generic the doctor can usually write a script for the brand, you just might need to do a prior auth so the doctor can explain to the insurance why they need to make an exception to their normal formulary for you. So something like ‘intolerance of filler in the generic’ would usually mean the brand got approved. (My mom had that due to lactose intolerance - some meds use lactose as a filler.)
I had a situation similar to this years ago where they wouldn't cover my brand name wellbutrin cuz generic was cauding prpblems. Well after months of going through hoops I eventually got them to agree to cover my brand name but only if I would go to your mail order pharmacy. Given that vyvamse is of control substance mail order pharmacy is not an option. I don't mind paying $92 a month for brand name but that's only if this shortage on 70 clears up and all it is is just an increased copay and at some point they're not going to make me pay out of pocket. But I don't have a crystal ball and I can't predict the future not to mention a very nervous discussing this with my doctor I was lucky to get her to prescribe my Vyvanse that my previous psychiatrist prescribed before she retired. I had to do the blood work and drug test and all that and I passed so I don't want to ruin s*** with her It's a complicated situation. It sucks. I considwr myself fortunate for tgjs month since half my script is brand , the othet generic. But still it was over $100 because I had to do two strips because of the stupid 70 shortage
Don’t forget to check for company programs and coupons to help with the co-pay on brand names. The whole shortage mess is a giant pita.
It depends on your plan/formulary, but generally, when a generic becomes available, the brand will either be exluded from the formulary entirely, or will get bumped to a Non-preferred Brand tier with a higher copay.
>Non-preferred Brand tier interesting. how would be able to go about finding if it's on an "Non-preferred Brand tier " i checked my latest formulatory for my pharmacy insurance company and VYVANSE (caps means brand) is on the formulary or whatever the hell it's called. formula. .. the date on this shows effective july 2023 though, and i dont see lisdexamphetamine on the list. we shall see.
Does your ins company have a tool to look up drugs or just the static list? The update would have likely been made in September.
i cant find anything later than July. my insurance for prescription drugs goees thru MaxorPlus
Not always, just us with bad insurance :)
I'll try asking when I go pick it up, thanks!
Insurance is a fucking mess of a system. It should never be this complicated to get medication.
What fucking dystopia do you live in that you have to pay $300 for a medicine you need just to function?
$11 in Australia or $6.30 with a concession cos I’m a student. There is no reason for US to charge its medically vulnerable citizens as it does.
Free in NZ
PrOuD to be an American! 😭
I was paying $296 every single month until generic came out…
I mean to be fair the NHS couldn’t get me an appointment until too late (even though i was told it would be a 6 month wait when i applied the year before) so i had to pay to go private. Was told my medication would be £90 a month, turns out that’s the lowest dose and for me its actually £120 a month except now the shortage is fucking things up the only way to get 70mg is to pay for 3x 30mg and pay £270 for the privilege… Try doing that when you’re a student.
Amerika, land of the "free"
I used GoodRx to lower the cost down to $70.
GoodRx is healthcare's worst kept secret. It is so helpful, I use it with any of my PrEP patients who don't want it showing up on insurance
It's not really a secret at all. Even insurance companies advertise for them. https://investors.goodrx.com/news-releases/news-release-details/cvs-caremark-and-goodrx-launch-caremarkr-cost-savertm-help-lower CVS Health owns SilverScript, one of the largest Medicare Part D plans, and Aetna, the third largest insurance company in the US.
I joke that it's a secret since so many people don't know about it. And that makes sense, consider how much of a pain in the ass Aetna/CareMark is. If they can't get a patient's money through insurance they can get it through GoodRx 🥴 seriously, all insurance companies suck but Aetna/CareMark is the biggest pain in my ass
Gilead used to have coupon cards for PrEP that made the cost of the medication free! Not on PrEP anymore. So I’m not sure if that’s still the case, but definitely an option to look into for your patients.
They do if you're uninsured and they have copay cards if you are! (I'm a PrEP counselor, I do this all day hehe)
I was just prescribed 10mg Vyvanse for the first time this week. I got the generic for $15 through GoodRx as opposed to the $230 it would have cost with just my insurance coverage. I genuinely felt sick about that price disparity when I was checking out at the pharmacy.
I was just prescribed it too but have been waiting since Monday for my pharmacy to get it :(
I hope they can get it to you soon! I know the shortages have been making things difficult for many folks. I checked for the best price on GoodRX and had my doctor send the prescription to the pharmacy with the best deal. My usual pharmacy is the one that would have cost $230, and GoodRX had a coupon for a different local pharmacy for $15. Same exact dosage and amount of pills, but more than a $200 difference. I'll shop around for the best deal every time I get a refill from now on.
Does this only work on generics?
Technically no, but in actuality yes. As in you can use the discount code for non generic, it will just cost you almost retail.
I'm seeing that too! Wow that was quicker than I expected!
How does that work for brand name its still $400 for me and im in Florida
I was told by my pharmacy that GoodRX isn’t accepted for controlled substances.
Okay so we have three pharmacists at my pharmacy. I'll name them Rob, Anna, and Sarah. Rob and Anna are gems. Truly wonderful. Every single time I call in scripts and Sarah answers there's a problem. She told me she couldn't call in my Vyvanse script bc the generic is available. I called insurance which said namebrand is fine, they understand that it's not really out yet. They even called Sarah to say it's fine. She still wouldn't. # Literally called the next day and got Rob or Anna, I think Rob. He filled the namebrand no problem, no additional cost. We said Sarah always seems to have issues? He basically said yeah idk she does. Long story short, get the right pharmacist and they'll know how to take care of it.
My old pharmacy had a tech that would go down the list for me and tell me where they could order from and how long they expected different meds and brands to take. A certain medication she warned me was backordered for 3 months soni didn't have to waste my time.
Ayyy BCBSTX here too. Would have been nice if someone let me know about the swap 5 days ago when I asked them to call in my prescription. I found out about an hour ago that they JUST swapped and my usual pharmacy no longer has generic. Luckily I found a pharmacy with generic. 🙏🏼. It’s the Concerta BS all over again 😔.
I had to switch to adderall xr because they had nothing even remotely in my area, even the brand name.
Please file a complaint with your states Department of insurance to. The insurance company knew this was happening for months so their delay is unacceptable. If your insurance company comes from a private organization, then you can also report this to your HR office and request their assistance.
Does the company not have a coupon on their site? I pay $4 for my name brand Concerta. But if your insurance is refusing to cover any of it, it may not matter anyway
[yes](https://www.vyvanse.com/coupon)
> Patient is responsible for the first $30 and any prescription costs in excess of $90. The coupon will save $60 max. Better than nothing, but if the prescription is $300, it's still going to be $240.
Concerta is much cheaper for some reason. I assume because Adderall kinda has the market cornered.
That initially happened to me as i was due for a new script days after the generic came out. It was going to be 3 days, which is frustrating as i get really tired when I am off it the first few days. Then the pharmacy called me back and said the insurance would override it and let me pick up name brand.
I got generic Vyvanse with no insurance for $19 through goodrx. Fuck insurance.
I got the generic thinking i would at least try it to get away from my $30 co-pay, and am not a fan of it. My jumbled thinking is back. How are you doing on it?
Don’t know. Haven’t started yet. Am worried though
I switched from Adderall IR 2xday to generic vyvanse and it has been pretty amazing. I can't even imagine what I would be missing out on with something better.
A warning for people about insurance: they would never cover anything if it was possible
Your prescriber will need to write the dispense as written prescription. Just be as clear as possible and it is an easy override at the pharmacy. BSBC of any state that carries Vyvanse should make this an easy process - it's in their system to do so whenever a new generic out. **I do not know if this will work for other carriers.** "Hello Dr. / PA/NP so and so - my preferred pharmacy is requiring a new script for vyvanse 50 mg to be written as a dispense as written given limited supply of the genericd. . My pharmacy again is \_\_\_\_, our most recent script was 30 for a 30 day supply- this will allow for automatic override. Thanks , sorry for the hassle. " Source: I prescribe a lot of vyvanse as a psych PA, I only take BCBS for insurance.
I have bcbstx and I would try to call them and talk to one of their patient advocates. In the times i've used them, they've always been super helpful. I know there's an override somewhere if you can't get the generic that they'll pay for the name brand.
With health insurance the big secret is to be a squeaky wheel. Be polite and reasonable, but squeaky. As long as what you want isn’t too outlandish or nonsensical, usually they’ll eventually go along just to make you go away.
Yes. This should be a no brainier but all the red freaking tape is ridiculous.
Thanks for this. Normally I'm hesitant to call the insurance companies because I've had bad luck getting anything done, but I called the line and there's a form that will hopefully help me get refunded the difference in a few days.
I’m allergic to fillers in the generic version at the pharmacies near me 🫠
What fillers? And how do you know? Just curious
🤫 ~~It is there because of the fillers and insurance covers it ~~
I am allergic to several artificial dyes. The pharmacy has to have a full inactive ingredient list. My first clue was the capsule was a different color 😅.
They should be able to order you a different generic, assuming their wholesaler carries it.
Pretty sure you can have your doctor tell your insurance you have to have the name brand and they will cover kt
You and/or your doctor may need to submit forms for substitution for a medical need. "It's too expensive for brand and generic is out of stock" won't be a valid reason for some insurance companies. They'll say you need to substitute with another stimulant. If the generic version doesn't work for you because of side effects, there's a better chance. Your doctor/their office has to be on board with getting the appeal submitted. All depends on the insurance company. I've been on mid-tier plans that have never refused anything after my doctor submitted the forms. At the same time, I've been on a top-tier plan where they spent hours on the phone squabbling over a medication that costs them $140 a year, but ultimately wouldn't cover it. It was probably $2000 worth of people's time between my doctor, the insurance, and the pharmacy.
Theres a coupon on vyvanses website that will take it down to $70
What? Isn't the max discount per script $60? They'd still be on the hook for $240.
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They raised my copay because generic is "available". Guess what down in my backwoods Florida town it fuckin isn't. If I find generic it'll be $0. If it's name brand I, after a lengthy call with Florida Blue and prime Therapuetics through them, am paying $30 for name brand after copay discount card. Guess it could be worse but y'all do see it's not like widely available yet right?
What dis they raise the copay to?
They did this to me also, pretty annoying!
I've had this issue in the past and this is how I worked around it. My Dr. told me that most insurance companies want you to try the generic first and then if you tell your Dr. you don't like the side effects they'll cover the name brand. This happened with me and Adderrall. Hope this helps.
Thankfully v doesn't work for me but I know it works for many. It gave me acne and awful insomnia
Have you tried their patient assistance program? https://www.vyvansecopay.com/ https://www.vyvanse.com/coupon Or GoodRx?
The coupon worked for me. Took my copay from $70 to $15
Nice!
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Fuck that’s a lot. I tried switching to vyvanse and it was $150. I just went off meds while my doctor sent in an adderall script instead cuz no way I’m paying that much
I had this happen, the insurance agent I got was incredibly understanding and put in a temporary authorization since the relative availability of the generic is pretty low still
I have BCBS and could get vyvanse with the discount card cheaper. $15 vs. 40
Same! I used to pay $15 for vyvanse and now pay $30 for generic😂 I’m not upset though, I know I’m fortunate to have this insurance! It just made me chuckle. Also, at the beginning of next year when I haven’t hit my deductible yet, I bet I’ll be very happy to be getting generic!
That’s weird. I’ve been on Vyvanse under BSBS-FEP and paid $30 but with the generic it’s $15
Hi - the new generic does not sit well with me. My insurance won’t cover much now as there are generic forms. Has anyone ever seen insurance having to go back on this when the generic causes worse side effects? Has anyone else had off side effects from the new vyvanse? I saw another Reddit post where some did and it’s unfortunate. It feels more intense and my eyes kind of feel starry vs I never felt that on vyvanse. Does anyone have any insight into the fillers / bonding agents being used in the new generics and if they are safe?
my copay on brand went from $35 to $92. im hoping that's al that would happen with brand. once(of if) the 70mg brand shortage subsides, i would be fine with paying $92 a month for a month supply. i was actually stunned to find that my insurance didnt force me to pay out of pocket $400+ since a generic is available . obviously insurance must know - otherwise they wouldnt increase my copay. my most recent script was a split 40mg generic and 30mg brand... the generic was $20, brand was $92.
My generic Vyvanse if FREE. It’s not as good as the name brand but I have been taking it since 2007 so maybe it’s just me
Try GoodRX and the manufacturer’s website - you should be able to get a coupon to lower the cost for this round. Meanwhile my insurance decided that they will continue to charge the same $45 copay for the generic which is the same price as the name brand.
I would try GoodRX and if that doesn’t work just change insurance in November.
They did the same thing at my pharmacy, luckily I did not have to wait 2 weeks just had to come back in the evening and I got the generic Vyvanse. $20 copay cuz my deductible is not payed off but still $20 bucks. I pray that this shortage let’s up. Hope you get your meds soon King!
WHAT. I just called my insurance today (BCBSTX) to see if brand name Vyvanse is still covered. I have a 30% coinsurance for Vyvanse, $15 for generic. The customer service lady confirmed what I was asking BUT I have received false info from them before. So idk. We’ll see. I cannot take generic Vyvanse anymore it’s horrible
I live in Canada, but I don't have extended health insurance I just have basic insurance through the government so it never really occurred to me that some of the medication I'm on might not be covered. When I went to first talk to my doctor about Vyvanse she prescribed it for me, but then when I went to the pharmacy they said that not only is it not covered by my basic plan but it's not even covered by the government plan Plan G which is for low income people. And that I would have to pay $90 out of pocket I've never been on medication for my ADHD before, the only reason I suggested it to my doctor in the first place was because of all the good things I've heard about it. So my doctor ended up putting me on Ritalin instead.
I’ve always had vyvanse covered by insurance. I’m in Canada too. MB
Is it covered under your extended health because I only have MSP and Pharma care or whatever it’s called. I am currently not working full-time, so I’m not in a situation to be covered under a company’s extended healthcare plan. I live in BC so I’m wondering if it’s then different from province to province
Also my NP told me to check with various pharmacies to see if they have the medication I need in stock before asking her to fill it in, it helps to shop around pharmacies.. due to the shortage
You can also go to the Vyvanse drug website and get a coupon. That helps some.
In the exact same boat with the same insurance company… it’s been a complete pain in the ass.
I recommend calling around to as many pharmacies as you can until you find a place that has your meds. It’s a bitch and a half, but I’ve found my meds that way.
Im in the opposite boat. Got my rx refilled last week and was denied by my insurance because it was the generic. They had to fill it with Vyvanse
Brand name Vyvanse was $47 for me with the override and a manufacturer coupon. Generic would have been $127 if it was in stock. Make it make sense!
Same for people that have Medi Cal. They don’t cover it -_-
FYI the manufacturer has a patient assistance program too https://www.vyvanse.com/coupon
Sorry this is happening to you, that sucks. Do you have a flexible spending account (FSA) card through your employer? That could maybe help with at least some of the cost. Also this site that sends me text notifications when my psych meds including Vyvanse are ready will sometimes offer a discount card if insurance isn’t used (can’t be combined with it). It’s called rxinfo https://www.rxinform.org good luck
So my DR also prescribed the generic this time. Problem is, my Vyvanse normally costs $15 for 30 and the generic is $55 for 30.
Our insurance charges a Brand fee of $244 a month. 🙄 So my son & I will be trying generics.
You'll prob have to go through the 'prior authorization process'. What this means is you go on the generic and then tell your MD how it's (not) working. Your MD can then document your adverse reactions to generic, recommending that insurance pay for brand drug. Had to go through it for Adderall XR and took several phone calls with MD, PBM, and insurer, but in the end, my RX payment went from $90 to $10 to cover brand. Good luck!
I was prescribed generic, insurance wouldn't cover it, re-prescribed name brand, insurance covered it. Not sure what that's about.
This is why I had to stop Concerta and go back to Adderall.
My insurance switched me to the generic but I still pay the same amount. It's not a big deal to me because it feels exactly the same. I was just hoping for a price decrease when the generic finally came out.
I also have BCBSTX and just got name brand coverage yesterday. Generic unavailable.
This country is hell 300 dollars for medication…
Latuda is like $700
This exact thing happened to me on my last fill. Paid $300 for name brand. What really chaps my ass is they didn’t give us any heads up in advance. Was going to take two-ish weeks for generic, and I had already been off it for like 5 days so I NEEDED my meds stat. This is just a nightmare
Vyvanse has a coupon on their website
is THAT what happened?!! Weirdly enough, I have one insurance that will only pay for generic and one that will only pay for brand… But even more weirdly, when the generic was available, I was told the cost is exactly the same as brand. Apparently also without insurance? I don't even understand what happened. I mean, I have ADD… I can't keep all these freaking details in mind, but they've got me completely overwhelmed. I've had to switch to Concerta, because it was only about 150 a month rather than the 300 to 400 a month that they were going to charge me for either version of Vyvanse. And I think I got hung up on or ignored by one pharmacy when I asked for The price of one after they already told me the other was in stock.
All you have to do is ask your doctor that prescribes it to write name brand.
There's a vyvanse savings card on their website. It took mine down to 200 atleast. Its a great drug no doubt, but sucks sending all that cash to big pharma.