Tuesday, September 23, 2014

Sunday, December 14, 2008 Ellette2005, Community Member, asks

Q: Insurance won't cover vyvanse for my son is there another medication like it that medicaid will ....

Christopher being Christopher<br><br>....cover ? My son was on Adderrall for a year when it simply didn't have any affect on him any more, three months ago his doctor switched him to one vyvanse 30 mg capsule a day. At first I was very secptical on how it was going to affect my son, but it only took a day to actually see some results ! I recently had to change my children from the private insurance they offerred at my place of employment over to the state medicaid. My son is on the well care program of Georgia. At which they won't cover the vyvanse for him for reasons unknown. We tried him on a 27 mg tablet of conserta but it had no effect on him whatsoever ! In fact I found him to be even more difficult to control. He has been off his medication now for two months and it's taking it's toll on his grades in school. Last month when we seen his counselor she prescribed him 10 mg focalin, but low and behold well care doesn't cover it either ! So my question is to you is there another type of medication like the vyvanse that may be covered by wellcare ? Reason I liked the vyvanse was my son actually seemed normal, he had patience manners and even was able to complete an assignment when asked without rushing through it just to get in done ! Please let there be an easy answer to my question, I'm not getting very much help from my insurance or doctor's office ! (By the way my son is 6 years old )

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Answers (7)
Anniston, Editor
12/15/08 7:56am

You should talk to your doctor about the various prescription medications and dosage levels that your son is being provided.  It looks like you are getting very different dosage levels for different medications.

 

In terms of reimbursement, Vyvanse is a long-acting version of Adderall XR, which looks like it is covered under the Wellcare preferred drug program.

 

Here are three links that should help you:

 

1.  a link to the vyvanse listing in the plan formulary:  https://www.wellcarepdp.com/formulary_drug/show/26040  what this seems to indicate is that vyvanse is covered as a generic -- that is, there is a generic replacement.

 

2.  A link to the listing in the 2008 formulary for adderall xr .  http://gaprovider.wellcare.com/WCAssets/georgia/assets/pharmacyservices_ga_preferreddruglist.pdf

 

The formulary on the Georgia WellCare sites says:  "You can ask WellCare Classic to make an exception to our coverage rules. There are several types of

exceptions that you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

WellCare Classic limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our

non-preferred tier (Tier 3), you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier (Tier 2) instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier (Tier 4)."

 

Here is the number to call to get clarity on what you need to do as a next step: 1-888-547-5252

 

If you get no help from the Georgia Wellcare people, another possibility is to apply to Vyvanse for their prescription assistance program, which will help you obtain the medication at a reduced rate.  Here is a link to Vyvanse's assistance program:

 

http://www.vyvanse.com/pdf/vyvansepapapplication.pdf

 

Good luck!

 

 

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buddy10462, Community Member
12/28/08 8:03pm

Hi - My name is Fran.  I am an adult with Inattentive ADHD, OCD, etc. I have been on dexedrine, addrell, and now my doctor put me on Vyvanse.  The reason your insurance doesn't want to pay for it, because since it is generic, it must be expense.  I find that it is smoother, and it lasts about eight hours.   I am on 70 mgs oCool

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buddy10462, Community Member
12/28/08 8:03pm

Hi - My name is Fran.  I am an adult with Inattentive ADHD, OCD, etc. I have been on dexedrine, addrell, and now my doctor put me on Vyvanse.  The reason your insurance doesn't want to pay for it, because since it is generic, it must be expense.  I find that it is smoother, and it lasts about eight hours.   I am on 70 mgs oCool

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Jmuller98, Community Member
9/18/09 4:38pm

Hi my name is Jennifer and I am struggling with the same problem. I have an eight year old who is on state insu. and they wont pay for vyvanse.  My dr is writing a letter the the insu trying to get them to pay. It's easier for Dr. to get through then for us.  If you have found anything out or have any advise let me know please. I am at jmuller98@yahoo.com

Thanks so much!

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c kile, Community Member
11/18/09 11:23am

I know what you are talking about what is a person supposed to do my insurance won't pay for it either

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onealy, Community Member
7/ 6/10 11:51pm

Google Shire Pharmaceuticals. There is a free program that assists with the medicine. If you fall into their income limitations you may even receive free. Just need to fill out & your Dr fill out the application and fax in. Hope this helps!

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Momfarmer3, Community Member
2/12/11 2:25pm


Hi
We went through a similar experience. Ask the pharmacist about a. PER form.   Tell them it is the form to request a prescription from insurance when it isn't usually approved. There are reasons that medicaid will approve a medicine. Like if nothing else is working.  The doc will have to list the reasons why he needs this med. And what meds have been tried.  
Hope this helps. 
Sent from my iPhone

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By Ellette2005, Community Member— Last Modified: 06/20/12, First Published: 12/14/08