Has anyone else had this problem? Were you able to deal with it successfully?

I was prescribed Dexedrine spansules last month: 10mg, 2x daily. My doctor has since bumped me up to 15 mg, 2x daily. My co-pay for each prescription was a reasonable $25.

Today, I received a letter from CareFirst Blue Cross/Shield which states (in part): "The claim cannot be processed because the medical documentation that the provider of service supplied to us is incomplete. The information still needed is symptoms for which services were rendered to include date of onset."

Should I call them and say, "Yup, I'm in my 30's and just realized last month that I had ADD."?

Or should I tell them the truth, i.e., that I've had ADD-like symptoms for years and just decided to get treated?

I'm terrified that I'm going to have to start paying full price for the brand name dex ($211 per month!!), even though I'm supposedly fully covered.

Any experience or knowledgable advice is very appreciated.

Thanks,
Chris

Blue Cross Blue Shield is notorious for denying claims for ADHD medications to adults, except Strattera and some generics. First, see if you can get a generic for Dexedrine, or possible Dextrostat. Also, if I'm not mistaken, you're probably dealing with Medco Health Insurance, and not with BCBS itself...Medco plays hard because they basically own the health insurance market.

Have your doctor send them a full report with the words "Dx ADHD" or something like it somewhere on the report. They should have to buckle, but they still won't pay all of it, you'll probably have a Tier III copay to make (~$30 with Medco)

Thanks for your reply.

A $30 co-pay I can deal with. I'll call them on Monday and see if I can work it out. If not, I'll take your advice and ask my Dr. to send them a full report.

I hate to say it, but even if I exhaust all options and am forced to pay $211/mo. for dex (argh...), I'll probably still do it. It helps that much.

What does "Dx ADHD" mean, btw?

Chris

Dx is short for diagnosis.

Generic Dexedrine is dirt cheap. ABRIKA D-Amphetamine, 60 X 30MG is just $82.00 at Walgreens (which would be a 2 month supply for you).

Blue Cross is balking at them trying to charge so much for an already available drug, if you take $40.00 worth or drug, stick it in a timed release pill (which isn't hard to make) and then charge $210.00 I think they have grounds to not cover it.

Yes, like I said, first try and get the generic. They almost always cover the generics, because they are dirt cheap. Chances are, they might even cover the generic normally, especially if it's Medco. I'm going to pull up the formulary and check for you right now.

Checked. Under Mountain State BCBS, Dextroamphetamine Sulfate generic is covered and "plan preferred," meaning they will pay some of it. Brand is non-plan preferred, meaning they require you to have "prior authorization" for them to pay for it, that is, your doctor needs to have talked to them and told them that. They will be very stubborn about this, unfortunately, and they may only cover it in children, too, like they do with Ritalin.

Go with the generic, because plan preferred means they will at least pay SOME of it.

My doctor may not go to bat for me when it comes to brand vs. generic.

He tried to talk me into the generic during my last visit, but because of some of the negative posts I've read about generic dex (specifically Barr, if I recall), I insisted on brand.

There is a pharmacy about 10 miles away that carries the Mallinckrodt generic, which I've read is identical to brand dex, so maybe I'll drive a little further and try that.

Thanks for all the helpful replies. I'm calling BCBS tomorrow and if anything interesting comes out of that conversation, I'll let you know.

Chris

Oh ya....that happened to me a few months ago. my Dr. had to get a preauthorization from my Ins. company.

All -

Thanks again for the informative replies.

Finally, after days of trying to get in touch with someone at BCBS who knew ANYTHING at all about the letter I received, I spoke to a supervisor this afternoon.

Interestingly, it turned out that the letter was not the insurance company's way of balking at paying for brand Dex when generics are available. For me, brand Dex is a $25 co-pay; generic is $5. Apparently, if I'm willing to shell-out an extra $20 per month for brand, they couldn't care less.

However...

The supervisor said they needed my Dr. to send them my complete medical records before they would pay the claim. "Why do you need that?", I asked.

"Because, if this was a pre-existing condition, we're not obligated to pay for it."

Uh oh.

My Dr. took copious notes during my first visit. He probably scribbled onto 3 pages while I told him my history. It would be pretty obvious to anyone looking at those notes that I didn't just come down with a bad case of ADD last month.

In a semi-panic, imagining having to shell-out $2500/yr. for meds, I called my Dr.

He laughed and told me not to worry. Told me that insurance companies are always trying to pull this sort of thing, especially with smaller companies (like the one I work for). He told me to fax him the letter and he'd take care of it.

I'm still not sure what he's going to do (maybe call and chew them out?) but I feel a lot better about the whole situation.

Chris

A "preexisting condition" in insurance language is a condition you've received medical advice or treatment for in the six month period before your coverage took effect. Sounds like you have absolutely nothing to worry about. :)