View Full Version : Insurance issues with quantity of pills (not total dosage)?


emperorpenguin
07-03-16, 05:09 PM
Hey all,

When I was taking adderall, my psychiatrist had previously said something to the effect that my insurance would cover a max of 90 pills/month. It seemed like she was saying this was true regardless of dose or whether it was branded or generic. :confused:

I'm now on 45mg/day Dex spansules (15x3) but want to switch to 40mg IR now that I know IR is available. Ideally I'd like to get 4x10mg/day, for 120 pills/month. Maybe even 8x5mg/day if that's possible, since I like to take 15mg in the morning and it would save me the (admittedly tiny) effort of splitting pills.

I know that there are several generic options at 5 or 10mg, but only Zenzedi brand for larger doses.

Has anyone ever heard of this "max number of pills per month" restriction, whatever insurance you might have (I have Anthem Blue Cross PPO)? It seems odd to me because glancing at prices, any IR option will be a LOT cheaper than spansules. And obviously getting the generic 10mg IR's will be much cheaper than brand 20mg. So I would assume they'd be all for it...and I'd assume if there were a restriction it would be total dose rather than quantity of pills.

I'm only asking here because it's been a PITA trying to get a straight answer from my insurance company, I've made a couple of calls and sent an e-mail and still don't know. Would a pharmacy tech be able to check, or is it one of those can't-find-out-until-you-try-to-fill-it situations?

Appreciate any insight.

Little Missy
07-03-16, 06:48 PM
Ask your doctor or get the script you want and see if it flies! :)

jeffb74
07-03-16, 10:08 PM
First your insurance company might normally only cover up to a certain amount even for generic drugs unless yoiur dr has a medical reason to prescribe morethan the insurance limit and the dr has to write a letter of medical nessicity . Quantity of pills depends on the state you fill the prescription in. In New Jersey, controlled substances such as Dextromaphetamine Sulfate you are allowed to have no more than 120 pills per 30 day prescription.( some pharmacies might refill every 28 days like CVS here in NJ but Walgreens is usually 30 days). But I think if your doctor gives a good medical reason why you should take more than the stated alloted amount for controlled substances you might be allowed to have more legally. Your local pharmacist should know the california laws on controlled substances allotted amounts per month. One of my local Walgreens pharmacists in New Jersey told me to call the Walgreens over the border in New York State, and for example in New York state there is no limit on controlled substances as long as you have a valid prescription and only for 30 days and no refills etc...

redrose
07-20-16, 07:01 AM
My insurance in CT will allow a max of 240 tablets per fill. I learned that when Dex was in short supply and I could only find 5 mg tablets. It's not a monthly max, just per fill.I got the insurance to override the cap because it was apparent there would be no 5mg available either in 2 weeks.
You must speak up for yourself if your doctor determines what you need. The insurance companies try to get away with a lot, but at the end of the day they are not medical doctors.

aeon
07-20-16, 01:03 PM
This is typical of the price-per-pill system much of the industry uses as opposed to a price-per-dose approach.

Insurance wants to limit pills per month, because total pill count determines what they will pay out.

Just as an example, I looked up generic Adderall IR tablets, and they come in 5mg, 10mg, 15mg, 20mg, 25mg, and 30mg tablets.

The price for 60 count is the same, no matter which dosage tablet I choose.

So if you pay out of pocket, and your doctor is good with the idea, and the pill can be split, it is always good to get the prescription for the biggest dosage possible.

Of course, that might not be an option with a CII med, and it doesn’t work for most extended-release meds.


Cheers,
Ian

sarahsweets
07-20-16, 02:55 PM
My insurance in CT will allow a max of 240 tablets per fill. I learned that when Dex was in short supply and I could only find 5 mg tablets. It's not a monthly max, just per fill.I got the insurance to override the cap because it was apparent there would be no 5mg available either in 2 weeks.
You must speak up for yourself if your doctor determines what you need. The insurance companies try to get away with a lot, but at the end of the day they are not medical doctors.

Holy cow! During the adderall shortage the only way to finagle things was for me to take 5mg ir tablets and I needed 180ct of them and my insurance wouldnt cover it and the pharmacist said it was against the law.

Laserbeak
07-20-16, 06:54 PM
My insurance has a pharmacy help desk where you can call and ask about any drug and whether it's covered and in what quantity, etc. Perhaps yours has something similar?

Laserbeak
07-20-16, 06:56 PM
Like Aeon said, pills are generally almost the same price, no matter what the dose per pill. In fact, I've run into situations where the higher dose capsule was cheaper than the lower dose of the same medication/manufacturer/everything.

C15H25N3O
07-21-16, 10:05 PM
Splitting bigger pills is always a good idea to save money if you have to pay them on your own.

Laserbeak
07-23-16, 10:24 PM
Splitting bigger pills is always a good idea to save money if you have to pay them on your own.

That works pretty well with tablets, but with capsules... not so good.

Sickle
08-01-16, 03:22 PM
My insurance covers 180 10 mg dexedrine tabs/month and 120 15 mg spansules. I take a combo of both (2 15 mg spansules and 3-6 10 mg tablets/day) and my insurance will cover both if I need it. But you can override if the higher dose is needed. I am allowed to get 90 mg/day with mine. But 60 mg is the FDA max so that is absurd.

Little Nut
08-01-16, 04:15 PM
Coming in late, hope I don't confuse this more, but I had similar issues w/ my insurance regarding Quantity Limits (QL) based on drug and/or "size" of pill/tab.

My Doc and Pharmacist kept hitting snags on what he or I wanted to try. My Doc and pharmacist tried to explain the details to me, but I guess I was too slow. I found the best thing to understand this is to get the "Drug Formulary" for your specific health insurance. (Mine is online.) It should be a large table of drugs. Find the "Amphetamines", "Psychostimulants", and "ADHD" meds. Look over the drugs you and your Doc are interested in trying. Estimate your dosage and check the Drug Formulary to see which drugs can be prescribed and dispensed w/o problems at the quantities you need and start with that drug. Then go from there.

In my case for amphetamines I needed QID dosing for IR, XR I would need BID, for Spansules probably BID w/ an IR booster, Vyvanse would be BID or once w/ a booster or 2. The only ones in the formulary that easily allowed this was Dexedrine IR and Desoxyn, so I picked dexedrine and negotiated w/ my Doc. I could have done Adderall IR, but with a bunch of splitting larger pills. and throwing in titration makes a mess imo. Also, if after trying this, nothing works well enough for you, you have all the info your Doc will need to get approval for a higher than allowed quantity or to try a drug not accepted. Also based on my current drug formulary, If I ever need to switch from Dexedrine, I would negotiate Desoxyn or Focalin w/ my Doc and I already have the reasons for choosing them.

emperorpenguin
08-07-16, 10:07 PM
Coming in late, hope I don't confuse this more, but I had similar issues w/ my insurance regarding Quantity Limits (QL) based on drug and/or "size" of pill/tab.

My Doc and Pharmacist kept hitting snags on what he or I wanted to try. My Doc and pharmacist tried to explain the details to me, but I guess I was too slow. I found the best thing to understand this is to get the "Drug Formulary" for your specific health insurance. (Mine is online.) It should be a large table of drugs. Find the "Amphetamines", "Psychostimulants", and "ADHD" meds. Look over the drugs you and your Doc are interested in trying. Estimate your dosage and check the Drug Formulary to see which drugs can be prescribed and dispensed w/o problems at the quantities you need and start with that drug. Then go from there.

In my case for amphetamines I needed QID dosing for IR, XR I would need BID, for Spansules probably BID w/ an IR booster, Vyvanse would be BID or once w/ a booster or 2. The only ones in the formulary that easily allowed this was Dexedrine IR and Desoxyn, so I picked dexedrine and negotiated w/ my Doc. I could have done Adderall IR, but with a bunch of splitting larger pills. and throwing in titration makes a mess imo. Also, if after trying this, nothing works well enough for you, you have all the info your Doc will need to get approval for a higher than allowed quantity or to try a drug not accepted. Also based on my current drug formulary, If I ever need to switch from Dexedrine, I would negotiate Desoxyn or Focalin w/ my Doc and I already have the reasons for choosing them.

Very good advice! As it happens I did in fact find the formulary a couple of weeks ago, before having read this, but I found it really confusing. I ended up sending them an e-mail about my specific situation and got a helpful reply a few days later. They said that there was not, in fact, a quantity limit on generic dextroamphetamine IR; I could in theory get 8 x 5mg per day if my doctor wrote it that way.

Anyway, my original question is moot but your response will probably help a lot of others! I ended up deciding to stay on the spansules. They're working great so why mess with it? My concern with an XR drug had been duration, as a 20mg Adderall even at 12:00 could really mess with my sleep. But that's proven to be unfounded; the spansules taken even a little later in the afternoon don't affect my sleep too badly, and I feel that they have shorter duration overall (maybe 4-6 hrs instead of 6-8 with IR Adderall). I think I'm one of those people who is really sensitive to levoamphetamine...