I am so aggrivated!! I just switched to Blue Cross Blue Shield and went to get my prescription filled for Ritalin LA. They don't cover it!!!! They do cover Regular Ritalin, Ritalin SR, Concerta, Metadate, etc.

I called to find out why it's not covered and of course they couldn't give me the answer. All they said was that I could have my MD fill out some appeal form.

They cover Concerta but not Ritalin LA? That seems a little odd since Concerta is much more expensive. I have been having a lot of trouble with medications not being covered by Aetna also. They make it really complicated.

I have 3 tier plan for prescriptions and Concerta is actually in tier 2 while Ritalin, Adderall Etc are in tire 3. Tier 1 are the generic versions.


I just got off the phone with BCBS and this time I found out why it's not covered. They said it's too new to the market and they are still investigating it before they cover it. Ritalin LA came out around the same time as Strattera which is also still being investigated.

I asked why BCBS took so much longer than other insurance companies to approve these meds and the person had no idea. I then asked for the name of somebody to contact about this and he couldn't give me any contact info. He told me there was a whole committe who make these descisions. I said yes, but people on committes have contact info.

I know it would be so much easier to just start by having my MD fill out a form to request that these meds be covered but I want to know why this process is taking so long for them to approve these meds!!!!

I am on BCBS, and they are very, very aggravating. They authorized my 20mgs, but then when I also started on a 5mg, they "supposedly" authorized it, but have yet to have actually informed me of that. As is, I've now paid for my last two months of medicine out of pocket, and they won't reimburse.

Very, very aggravating. I don't know their policy on Zoloft, either. Where do you access your policy information? Technically, I'm on my dad's coverage, so I don't have the paperwork myself...

BCBS of GA is a worthless company. I have the HMO plan, but all they want is my premium and they constantly try to get out of paying claims. I, too, have been frustrated with their prescription policies. It seems that they like to change the rules on the fly as it suits their needs. They will pay for the generic Ritalin SR, but not the brand. BCBS has a 'Preferred Drug Formulary', and if your med is not on it, you can forget it being covered. They will not provide you with a copy of their 'Formulary'; they will only send you a partial "popular drugs" list. In addition, they change their list regularly. If you call them and ask them about specific drugs to see if they're "covered", you will find a pattern indicating that they only cover generic drugs, unless there is NOT a generic version or the brand is not much more expensive than the generic. If you want to get a drug "covered" that is not on the 'Formulary', your Dr. will either have to make a verbal request or a written request (5-day turnaround) for such. Regardless of what their ignorant employees may tell you, the answer will almost assuredly be "request denied because patient did not experience unbearable side effects from the generic version".

Actually, generic Ritalin is only "plan preferred" under BCBS if you are age 5-12 (why it's covered for ages 5, when it's contraindicated by being under 6, I will never understand...)...then again, my BCBS (Mountain State BCBS) plan does all Rx policies through Medco Health, so it could be different for other BCBS groups...

I have seen billing insurance from the other side of the pharmacy counter that insurance companies often incidentaly "leave out" key point for what they cover, for a real explanation of why they dont cover a certain med, good luck getting one, ive been on hold with them for an hour just to get an automated response saying to call back later. Many insurance companies (keep in mind i practice in Tennessee) that i have billed will re-imburse the patient, say you pay out of pocket then get your pcp to call the insurance company (they either have a number or just give them the one off the back of your card) get them to manually override the claim, and them go back to the pharmacy have them re-run the script under your insurance agian, and then when it goes through, they refund you the difference between what you paid and your co-pay. Most insurance companies either send you a drug formulary or you can access it through their web site, it will give you every drug that they cover and what tier (i.e. what co-pay you pay) it is in. Most Three tier plans go Tier 1- low cost generics and some cheap brands, Tier 2- More expensive generics and brands, and then Tier Three is reserved either for new (i.e. Strattara) or Brands that have a generic in either Tier 1 or 2 that they would rather you have. Insurance companies want you to use generics whenever possible b/c it saves them more money, and also the pharmacy makes more money per script on generics than brands, go figure. Thats why you have to watch it if you dr. signed that generic substitution is allowed they most time will fill it for generic without asking you unless you tell them you want brand. and some times insurance will only pay for certain brand name medications if the doctor signed that only brand is acceptable, their is an override field that we type either that the doctor specified or the patient requested brand but the dr approved generic, sometimes that can affect it. What it comes down to is that we (i.e. pharmacy staff) dont know what your co-pay will be untill we submit the claim electronically and the insurance company responds and tells us what to charge you, thats all the control we have over that. My advice, educate yourself about your specific plan and tell your doctor that if you have a specific med that your on, he may have to call for an override, your friendly pharmacy staff will tell you if thats the route to go, or just ask your doctor, they want you to save money to,

Metdate CD is comparable to Ritalin LA in terms of how the extended release works and the levels of ritalin released over 12 hours (the have nearly identical pharmacokinetic profiles). So, I would say change to Metadate CD. However, Metadate ER, Ritalin SR, and Concerta are all different as far as their pharmacokinetic profiles. Thanks

I just discovered this myself. I've just been diagnosed with ADD. The Dr. gave me a prescription for Ritalin LA because he said some other med wasn't covered by BCBS. I go to the pharmacy, they tell me LA's not covered. I check the BCBS website for covered meds. It says LA comes in tablet and capsule, and they cover one but not the other (I forgot which). I go back to the pharmacy. They tell me the other form (tablet or capsule) doesn't exist! So I went to a different pharmacy for a second opinion, and get the same story.

So I called BCBS and get the line that the Dr. can appeal, but It could take several days to be approved, and it would be tier 3. They said regular Ritalin would be tier 1. So I called the doctor to try to get it switched to regular, but he refused to do that for some reason, instead he decided to go the appeal route.

Frustrating. I'm glad my employer pays 100% of the premium for BCBS, so it's hard to argue with free, but it seems that every medication I've tried to get filled through them has been tier 3 even though there's no generic alternative.