Monday, January 31, 2011

ADHD Meds and the Pharmaceutical Racket

Our two older kids have ADHD. Maybe you think that condition is over-diagnosed or you don't believe in medication. I'm not trying to open a can of worms. We definitely do believe in behavior modification and that there's no magical pill that will solve anyone's problems. But for our kids, medication is a necessary tool. When school work began to suffer we began the medical intervention.

Until recently Tyce and Mary were both taking the same med, non-stimulant Strattera. Their prescriptions cost $80 each a month, until Tyce's dosage increased and doubled to $160. The price, coupled with everyone's increasing dissatisfaction with the medication (more on that later), led us to seek a new option.

After meeting with the neurologist, he prescribed Metadate, a 12-hour stimulant, and a tiny 5mg pick-up for homework time later. These meds have worked wonders for Tyce and seem to be a great fit. He is more "himself" on the Metadate and can really concentrate when he needs to. He seems positive and less aggressive. When he took that 5mg one night he wrote the 20-page novella, something I'd never, ever seen him do. Another benefit of this drug is that the prescriptions are only $5 each because there's a generic. Talk about a financial blessing.

So feeling energized with that recent success, I took Mary in for the same reason. After hearing my concerns he prescribed a popular new med, Vyvanse. When I went to pick it up at the pharmacy, guess how much it was . . . $179! For one month! That's like $6 a pill. I told the tech I wasn't going to pick it up until I talked with my insurance company.

So for now she's on the same ineffective medication and she's almost out. I am so frustrated. A lot of people report an increase in aggression while on Strattera, and I've definitely seen that in both kids (but manifest completely differently). For Mary, I don't even think the Strattera helps much with focus or concentration. However, if she's late in taking it, or--heaven forbid--skips it, that's when all the major, major blow-ups happen. So I feel like I can't just take her off without something else to replace it.

A friend at church has a teenage grandson diagnosed with ADHD and his insurance paid for a brain scan. Those are extremely effective in literally pinpointing the areas of increased and decreased activity so the proper medication can be prescribed. Unfortunately, most insurance companies do not cover brain scans. They prefer that you guess over and over until you find the right fit or give up.

Who gets to say what is and isn't covered? My younger boys receive Medicaid, since they were designated a special needs adoption*. I am so grateful for the Medicaid. But it makes me see the disparity in the options for health care between the younger kids and the older; the twins' care is 100% paid for and they can see anyone they want, while the older kids go to the physicians who take our insurance, and we get nickel-and-dimed for $30 here or $50 there. Is that fair? Maybe it's unfair that our twins get such a good deal. Maybe I'm unwittingly advocating for universal health care . . . I don't know. We all want it but no one wants to pay for it.

Remember that short time Cameron was on Intuniv? I think that ran about the same price as the Vyvanse. Anytime you get a whole booklet of literature with a pharmacy discount card inside, you know it's going to be a bank-buster. I think it would be nice of the doctor to say, "By the way, Mrs. Jones, the price of this med will be roughly the same as your car payment." But if it's the right fit for your diagnosed medical need, why should it be cost prohibitive to get it?

Sometimes I get the feeling the drug companies are in the physicians' back pockets. Every time I'm in a doctor's office a pharmaceutical pretty-boy breezes in, dropping off pens and packs of neatly-boxed pills. One time one of the kids' doctors was late because he'd been at a drug company's luncheon!

But on to a practical matter: Have you ever fought the insurance company? Is it worth it? Should I ask about a better rate for medication or is that like asking the airline company for a $5 seat? Should I ask if they will pay for a brain scan, and if they say no . . . should I hound them or just accept the answer? Does anyone know?



So you're probably wondering what my new calling is. Well, they didn't sustain me on Sunday. So mum's the word for another week. Sorry to keep you on the line; I really thought it would be this week. BUT! You can guess and I'll tell you if you're right. Just kidding. Kind of. No, that would be wrong. Or would it?

To end with something happy: The kids all went to school today without drama or tears. Hallelujah!

*  Children considered special needs adoption need to fit two or more criteria, including being: racial minority, over the age of 2, a sibling set, physically or mentally challenged, or medically fragile. There are more but I can't remember them all. Kids who are considered a special needs adoptive placement usually receive either a state or federal subsidy to help defray the costs of their specialized care, sometimes including Medicaid.


Bryce said...

and before Medicaid kicks in, or private insurance pays. Medicaid only pays what the insurance won't cover.

Bryce said...

"our" private insurance

Jenn said...

This is Aunt Lynn using Jenny's account again. Doctor's and insurance companies and the price of medicines get my blood boiling. Thank goodness Tyce is being helped but that doesn't help Mary. I would at least talk to the insurance company about the brain scan. I've never fought them but it might be worth a try. Good luck and you have my support.

Rebecca and Co. said...

Update: The insurance co. knocked it down to the second tier, and then I got an 11-month half-off voucher by mail. I'll take a $40 payment over $179 any day. I probably could have had a similar deal for the Stattera but I just didn't know to ask.