View Full Version : How comprehensive is your health insurance coverage for ADHD/ADD?


Wish
04-11-07, 11:50 AM
I am curious about other people's experiences with getting insurance to cover treatment for ADD/ADHD. Does your insurance cap the number of visits they will cover to a psychiatrist or a psychologist? Do you have to pay for a lot of your treatment out of pocket?

My insurance covers a maximum of 25 visits to a psychiatrist per year.

cwbyjohnson
04-11-07, 02:27 PM
My insurance covers 24 visits and all legend drugs with a small copay.

DianeS
04-11-07, 03:30 PM
If my husband's coverage has limits on the number of visits, he hasn't run into any of them. He sees his psychiatrist every 3 months, and his psychologist every 2 weeks. There is a copay for each of them, insurance picks up the rest.

For medications, he has a weird system.
First, 100% of the meds is paid by insurance up to a certain amount (we hit that amount in Feb),
then 100% of the cost is paid by the patient up to a certain amount (we hit that amount at the end of March),
then 80% of the cost is paid for by insurance with the patient picking up the remaining 20% up to a certain amount of out-of-pocket expenses (we tend to hit that amount in the fall sometime),
at which time the insurance will begin to pick up 100% again until the end of the year.

Confused? So am I. But it works, and it only hurts in Feb and March of each year.

Wish
04-11-07, 05:47 PM
That sounds like a good plan. I've never had an insurance plan (even growing up when I was on my parents' health insurance) that covered 100 % of a drug. That's pretty sweet that he only has a copay for his drugs one or two months out of the year.

Because of my experiences with insurance companies and because of the fact that they seem very motivated by profit margins, I have to ask if there's some kind of catch to his plan? Do they charge higher premiums or something to make up for covering the drugs 100 %? If there's no catch than I want to work where your husband works haha.

DianeS
04-11-07, 10:14 PM
I must have not explained it well... let me try again.

Jan - Feb: Insurance 100%, Hubby 0%
Feb - Mar: Hubby 100%, Insurance 0% :eek:
Apr - Nov: Insurance ~80%, Hubby ~20%
Nov - Dec: Insurance 100%, Hubby 0%

So the catch is that he has to pay 100% of the cost himself for about a month and a half. Those six weeks are AWFUL because it costs us close to $1,200. I don't understand how people without health insurance can do it - I guess the answer is they don't.

The co-pays are OK. Most people in his office don't even get through the first bit unless they are on some major meds like heart pills or insulin or my hubby's Concerta/Trileptal/Lexapro/Etc mix.

Wish
04-11-07, 11:11 PM
Don't worry, you explained it fine. I just had an ADHD moment haha. Yeah I can imagine those 6 weeks would be especially hard for someone who has a chronic condition that requires daily, expensive medication

cwbyjohnson
04-11-07, 11:15 PM
The only reason I stay at my current job is my health insurance. I discovered that with the drugs I take for OCD, Bipolar II, and ADD, it comes to well over $10,000 a year, and that doesn't include the cost of the psychiatrist!

Wish
04-12-07, 11:48 AM
I hear ya on that. Is $10,000 the cost for name brand drugs or generics? I certainly wouldn't be able to afford the name brand adderall xr and wellbutrin that I take without insurance. I'm not even sure if I could afford the generic versions of my drugs without insurance.

amythyst
04-13-07, 03:57 PM
My current insurance covers 80% of prescriptions so that's not bad but it only covers $300 a year for psychological services...yep, that's right 2 VISITS! Can I work where you work? hehe

cwbyjohnson
04-13-07, 04:42 PM
I take one drug called Abilify and it costs over $700 a month, and it's a brand name I believe, that's the bulk of the costs. The rest are generics though I think. I take a lot of them, Depakote, Abilify, Xanax, Lorazepam, Propranol (sp?), Luvox, and Dexedrine.

UnleashTheHound
05-16-07, 04:37 PM
I have a $20 copay for Adderall, but this year, the insurance co is trying to push people towards using the mail order pharmacy for long term prescriptions. Now if you get the same prescription filled at a drug store 3 time in a row, the copay increases the third time to $40. The copay is cheaper to mail order, but you need to get a minimum of a 90-day supply.

Skully
10-16-07, 07:35 PM
My health insurance only covers 50% of mental health benefits. It covers the drugs under the normal 3 tier system ($15, $25, $50) but for pdoc appointments and therapy, I only have 50% coverage. Stinks, but I have to live with it. The worst part of it is, I WORK in mental health!!!

hollyduck
10-16-07, 11:40 PM
I must have not explained it well... let me try again.

Jan - Feb: Insurance 100%, Hubby 0%
Feb - Mar: Hubby 100%, Insurance 0% :eek:
Apr - Nov: Insurance ~80%, Hubby ~20%
Nov - Dec: Insurance 100%, Hubby 0%

So the catch is that he has to pay 100% of the cost himself for about a month and a half. Those six weeks are AWFUL because it costs us close to $1,200. I don't understand how people without health insurance can do it - I guess the answer is they don't.

The co-pays are OK. Most people in his office don't even get through the first bit unless they are on some major meds like heart pills or insulin or my hubby's Concerta/Trileptal/Lexapro/Etc mix.
From wikipedia Medicare_Part_D, which sounds similar:
Costs to beneficiaries

The MMA establishes a standard drug benefit that Part D plans may offer.[5] (http://en.wikipedia.org/wiki/Medicare_Part_D#_note-4) The standard benefit is defined in terms of the benefit structure and not in terms of the drugs that must be covered. In 2007, this standard benefit requires payment of a $265 deductible. The beneficiary then pays 25% of the cost of a covered Part D prescription drug up to an initial coverage limit of $2400.

Once the initial coverage limit is reached, the beneficiary is subject to another deductible, known officially as the Coverage Gap but referred to more commonly as the "Donut Hole (http://en.wikipedia.org/wiki/Donut_Hole_%28Medicare%29)," in which they must pay the full cost of medicine. When total out-of-pocket expenses (http://en.wikipedia.org/wiki/Out-of-pocket_expenses) on formulary drugs for the year, including the deductible and initial coinsurance, reach $3850, the beneficiary then reaches catastrophic coverage, in which he or she pays $2.15 for a generic or preferred drug and $5.35 for other drugs, or 5% coinsurance, whichever is greater. The $3850 amount is calculated on a yearly basis, and a beneficiary who amasses $3850 in out-of-pocket costs by December 31 of one year will start their deductible anew on January 1. Most low-income subsidy patients are exempt from all or part of the donut hole and the deductible.

This sounds to me like a way of forcing people off their medication , frankly. The initial $265 is perhaps not impossible for all but the poorest people,but the following problem of having to come up with 75% of the cost of the medication will get rid of quite a few more, and that $3800 out-of-pocket expenses is a huge chunk of a poor persons before tax income. a minimum wage of seven dollars an hour still only ends up paying you about $12,000 a year. After taxes, out-of-pocket medical expenses would run about half your take-home pay.

The article says that "Most low-income subsidy patients are exempt from all or part of the donut hole and the deductible." But how low would that income be? I don't know.

I find it amazing that so many people in the states take the medication that's prescribed -- I don't know how they do it. When you're at that level of income, it's not like you can save up during the year so as to pay your way over the medication gap -- and you can't just skip those six weeks, because you have to build up that $3800 out-of-pocket payment in order to access any further support from Medicare.

Disgraceful.

Ducky

Chrisles
03-22-08, 07:14 PM
Mine is Blue Cross & Shield Anthem. It covers Concerta and Addrall XR. Not Focalin (IR or XR) and Vyvanse. And everything else inbetween. Doesn't cost me then $20 for the Tier 2 (Addrall XR and Concerta).

I can visit and Menal Health Care Provider 45 times a year. So about once every two weeks for a Phychotherpist and once every three weeks for a Phychiatrist.

This is more then I could have ever hoped for and I hope that it never changes.