First time INS has denied early hard copy script

[Vagusnervex]

Hi there,

Just looking for some advice or comment from others who may have experience this problem.

I have been on Adderall for 10 years now with much success and really life-changing results. My dose has been 60mg IR for a few of those years now. Occassionally, due to increased needs for focus during particularly busy school times, I will take an extra 10mg. I have told my doctor about this as that leaves me a bit short sometimes. He didn't have a problem with it but could not write for more because 60 was the max dose allowed.

This hasn't been a problem until now. The pharmacy I use to use never had problems with the INS covering my hard copy scripts if they were a few days early. I had thought that I had read that the hard copies are considered new scripts and are not like refillable meds in which early refills are an issue.

Due to the Adderall shortage, I had to find another pharmacy who had it in stock. This wasn't a problem the first time. Almost a month later, I take my new script to them and for the first time ever, I am told that the INS says it is too early. I was able to get an override but I am worried about next month when I will be in the same situation again. I'd rather just pay out of pocket to avoid the anxiety but I'm not sure if I can do this.

I am wrought with worry about this. I have been on this drug for so long and it makes such a difference in my life. Besides from the occassional extra 10mg, I've been stable on this dose for many years and I only have it prescribed by my family doc of 10 years!

Can anyone share any similar experiences? Thanks!

[buknoy]

Hi, I've had a similar experience on two levels. One with filling to early. I believe that as a general rule, 5 days before your 30-day supply script runs out, most insurances will not require an override. But I think the number of days early, where you would need an override, will vary depending on: the actual price of the med, the insurance company, and your personal circumstances, such as, you're getting ready to leave on vacation 1 week before your month supply is depleted; or this was your first experience with adderall and you got a bad reaction after being on it for only a week, you go back to your doctor who gives you an RX for Desoxyn, etc. You may or may not have to get an override depending on these things.

Indeed, hard copies are new scripts, but to the insurance company, they're just another chronic med, that you refill every month. But technically they are new scripts, so you could simply just pay out of pocket for, regardless if you had filled a different adderall script just a few days earlier, for instance.

The 2nd way I can relate, is that my medical provider really doesn't like prescribing, or even refilling meds that he feels should really be written by a psychiatrist. This is probably where your doc is coming from by insisting on 60mg max/day. In most, if not all reference publications, the max. dose is considered as 60mg a day, and that "very little benefit is obtained with higher doses." quoting a book i have in front of me. However, doctors who specialize in psychiatry and ADHD routinely prescribe very high doses. My script is 120mg per day, for instance. I actually take 60-120 depending on my symptom control on any given day, but this is an example of how a doctor, who may or may not (most likely does not) have any experience with ADHD, wants to stay within the boundaries of what the max dose is recommended in the literature, but the specialist who most likely has a lot more experience with ADHD, is willing to write for twice that amount. See the difference?

Let's say I overdose & die, and it was my medical doctor who wrote my last prescription because my psychiatrist was out on vacation. The medical doctor would most likely be held liable for giving me a 120mg a day of adderall script, even though I've been on that dose for a year, because any adderall dose higher than 60mg/day is beyond his scope of practice.

Seeing an ADHD specialist is ideal in your case for the reason that he could give some leeway if you need an extra 10-20mg per day. Your medical doctor could do that too, as long as your regular daily dose was, say, 30-40mg, as he could give you a leeway up to a total of 60mg which is within his scope of practice.

Hope this helps.

[Vagusnervex]

Thanks for the advice.

I got the override on 7/30 after I was told the ins would cover it on 8/13. I still had a few days supply so, and now I have a 37 day supply which will run out on 9/6. Should they cover it around 9/13 without a problem? If they will, then I will still have to cut my dose so that I have something for those few days in september.

The easiest answer is to just go elsewhere and pay cash when I run out on 9/6. I know I've done that before a couple of years ago, but for some reason that scares me now. Once I get through this situation I'm sure as hell am only ever taking 60mg so that I don't have to stress about it.

On the doctor front, I have a very good rapport with my long-term doc. Once this rough patch is over, I'll make the dosage he gives me work. I really don't want a different doctors name writing my script for fear of looking like I'm doctor shopping.

[BR549]

He didn't have a problem with it but could not write for more because 60 was the max dose allowed.

Actually, there is no maximum adult dose "allowed" for Adderall IR. It's not approved for use to treat adult ADHD. It is used to treat it, but it's not been approved by the FDA for treating adults with ADHD, therefore there is no recommended maximum dosage. It IS approved to treat adult Narcolepsy.

As far as a dose being "allowed", nowhere does it say this in the manufacturers prescribing guidelines or medication guidelines. There are recommended starting dosages. What those guides DO say is this:

http://www.accessdata.fda.gov/drugsa...522s040lbl.pdf

Narcolepsy:
Usual dose 5 mg to 60 mg per day in divided doses, depending on the individual patient response. Narcolepsy seldom occurs in children under 12 years of age; however, when it does, dextroamphetamine sulfate may be used. The suggested initial dose for patients aged 6-12 is 5 mg daily; daily dose may be raised in increments of 5 mg at weekly intervals until optimal response is obtained. In patients 12 years of age and older,
start with 10 mg daily; daily dosage may be raised in increments of 10 mg at weekly intervals until optimal response is obtained.

And for treating ADHD:

Attention Deficit Hyperactivity Disorder:
Not recommended for children under 3 years of age. In children from 3 to 5 years of age, start with 2.5 mg daily; daily dosage may be raised in increments of 2.5 mg at weekly intervals until optimal response is obtained. In children 6 years of age and older, start with 5 mg once or twice daily; daily dosage may be raised in increments of 5 mg at weekly intervals until optimal response is obtained. Only in rare cases will it be necessary
to exceed a total of 40 mg per day. Give first dose on awakening; additional doses (1 or 2) at intervals of 4 to 6 hours.

Have you talked to your insurance company about this? I know that I can get my Adderall prescriptions filled anywhere from 5-7 days before my 90 day allotment is gone. I don't take extra either.

[salleh]

this link is to the first place I found that talks about "off label" prescribing ....and the site is owned and run by a pair of ADD docs .....

http://adultadd.info/treatment/stimu...issues/dosing/


it might hel[pe with your main docs reluctance to sribe more.....I did the same thing ....and was lucky enough to fhave a pdoc who understood .....and then the trick is to find a pharmacy who won't give you a bad time .....


I have a 300 10 mg scrip for dex IR ....or a 90 30mg scrip for adderall IR depending on what is available ...that cursed shortage ! ....


good luck ....

[Vagusnervex]

I don't think my doc would have any problems with writing for 70mg instead of 60. I had brought it up in passing a few years ago but never seriously followed up on it. But I just saw him last week to get my next 3 months of scripts- written for 60mg of course. Now Im stuck with the problem of running out in sept. and I feel bad about taking his time up with this hole that I've gotten myself into.

If I do see him, how could this get sorted out? If he wrote an additional script for 10mg wouldn't INS have the same problem? Even if they didn't, there is the whole shortage problem.

P.S Everyone's advice is really helping me calm down about this so thanks guys.

[purpleToes]

We can tell you what how we think the insurance company will make its calculation, but they don't all do things the same way. Since you're trying to plan ahead here, it's best to ask your insurance company when you are next eligible to fill. This is a perfectly normal, non-drug-seeking question to ask them, so don't be afraid it will flag you in some way. People need to plan.

I'm happy to offer a guess, though, based on experience with my own plan and in my state, that your eligible fill date is based on your most recent actual fill date, so it's possible that you could be eligible again on 8/30, assuming the 7/30 one was a 30 day supply. I can also imagine a 9/6-8 date based on the insurance figuring you still had 7 days worth on hand when you filled 14 days early, allowing you to fill when you're down to 5-7 days supply. It's hard to imagine they'd make you wait until 9/13 unless they argue that you should have even more than 37 days worth on hand due to the previous early fills.

Even though it never seemed like a problem before, I doubt the early fill denial had anything to do with going to a different pharmacy, since most pharmacies have real-time electronic claim processing and the insurance company is aware of all your Rx claims no matter what pharmacy you go to. It probably had more to do with the unusual request to fill 14 days early or the pattern of early fills.

From the insurer's perspective, they only want to be paying for 30 days of medication per month, on average. They allow some flexibility to fill early now and then, but I think they're going to push back if you fill early habitually and it's not offset by late and on-time fills. They have an interest in in preventing you from stocking up an extra month of two of medication per year at their expense.

If you've been coming up short every month for a few years already, then it really is long overdue that you discuss it with your doctor. Put your embarrassment aside and make another appointment.

If your doctor agrees you need an additional prescription, there's no need to take it to a different pharmacy. If they have questions about the legitimacy of the Rx, they call your doctor to check on it. If insurance won't pay for it, find out the exact specific reason for claim denial and then call your insurance customer service to ask for the steps to get it authorized. Better yet, call before you even meet with the doctor and find out if they require any special authorization for quantities above a certain amount.

[buknoy]

Originally Posted by BR549

Actually, there is no maximum adult dose "allowed" for Adderall IR. It's not approved for use to treat adult ADHD. It is used to treat it, but it's not been approved by the FDA for treating adults with ADHD, therefore there is no recommended maximum dosage. It IS approved to treat adult Narcolepsy.

What? No maximum?? Better yet, no maximum "allowable"? That is awesome!! (Cuz I really need to go up on my dose. Thanks for that.)

So what does a physician use to determine the dosage he'll prescribe? A dartboard? Random lotto numbers?

Or how about when a doctor is defending himself on trial in a wrongful death case related to his prescribing of adderall?

You mean the "information" contained in this NDA leaflet, that was glued to the top of my adderall bottle, is gonna justify his actions and get him acquitted?

How absurd!

No, this doctor will be judged against what a reasonably prudent doctor, with the same level of expertise would do in the same circumstance. (And yes, there had better be a maximum allowable dose).

That brings me to my point (which is only an opinion), that a "maximum allowable dosage" can vary from doctor to doctor depending on the level of expertise. A general practitioner who may use generic, published guidelines of the drug manufacturer; compared to a specialist who has "knowledge" about guidelines but also draws on his experience in practice and the practice of peers in the same specialty.

This is what accounts for the difference in prescribing practices. I wanted to encourage Vagus to see a specialist, so as to not be limited to care from a doctor who definitely has a maximum allowable dosage, and follows a more rigid practice, not taking special cases into account.

[salleh]

when a doctor of any kind prescribes a medication for a patient, he or she should have a damned good idea why and what for that dosage is allowed.....any good doctor will.....

however, that goes hand in hand with a good doctor will also know if his/her patient is someone who falls outside the usual parameters of what "most " people are prescribed ......and because they have a reason, if the DEA or any other gov't agency questions them, they just give them that reason ...assuming that said doctor doesn't prescribe every one of his/her [patients large dosages......there should be no problem...


it's when a doc goees way outside guidelines on a large number of patients will larger than normal doisages that trouble can tiurn around and bite them ....but even then ...if the doc has good reason and proves it ....they will back off.....


it's the pill mills that the gov't agencies are out to shut down and prosecute....not legitimate docs taking care of their patients legitimately .....and it's too dam*** bad that the gov't scares good docs into not meeting their patients needs bacause of fear of what the gov't might do.....

[Vagusnervex]

I am also thinking/hoping for a 9/6-8 fill date. Before I got the override, the pharm quoted the INS would fill 8/13. Exactly 30 days from 8/13 is 9/11. So they should let me fill around 9/6-8. As long as I skip a couple of doses here and there, I will be fine and have enough.

I'm going back and forth over calling the INS. My experience with dealing with them has been that of pulling teeth. I also feel like they will simply state that it will not be filled until 9/11 so that I'm left with the impression that they are that rigid. These companies seem to have adopted an anti-customer service attitude over the last couple of years.

Honestly, after all the hand-wringing I've done over this, I'm willing to adhere to the 60mg dose from now on. Once this crisis is over, I will still make an appt with my doc to discuss options for a more effective treatment plan. He has been trying to get my to try Vyvanse for some time now yet I'm not sure why. I don't know much about it and I feel as though Adderall is the strongest thing out there anyway.

I had more to type but the sustained stress is pushing me to go to bed. Hopefully I'll remember what I wanted to say/type tomorrow.

[BoredWes]

You might want to try switching over to a 90 day prescription. Most insurance companies will allow your doctor to write you two prescriptions at the same time. One for your immediate need (generally a 30 day script) and then one for your maintenance needs (your 90 day script).

it's a complete pain in the butt to setup at first, but well worth it in the long run.

[purpleToes]

Originally Posted by BoredWes

You might want to try switching over to a 90 day prescription. Most insurance companies will allow your doctor to write you two prescriptions at the same time. One for your immediate need (generally a 30 day script) and then one for your maintenance needs (your 90 day script).

it's a complete pain in the butt to setup at first, but well worth it in the long run.

Sorry, I have to disagree with BoredWes on this one. I don't think that's good advice for someone who's already having difficulty managing 30 day prescriptions correctly. (It's also technically not quite correct - the DEA places an absolute restriction of multiple schedule-II prescriptions to 90 days total.) Instead of being a few days short, OP could end up a few weeks short next time.

Vagusnervex, it sounds to me like you're having a lot of anxiety about this situation - avoiding talking to insurance to find out the date, not wanting to involve your doctor, wanting to somehow solve this yourself without him knowing. I can imagine how embarrassing this is for you.

I want to urge you to approach your doctor, with whom you've said you have a good rapport, and figure out what to do. If your situation is as you described, it's not that bad. It was a mistake to think you could keep using 30 days of meds every 25 days and it not be a problem, yes, and you realize it now. Maybe you truly need a higher dose or maybe you need some different strategies for controlling your use. That's what your doctor is there to help you with.

It sounds like you're thinking if you could just start fresh, without your doctor ever knowing about it, you could keep this from happening again. I believe your good intentions, and maybe you can, but if it was only a matter of willpower, don't you question whether you could have kept to your prescribed amounts all along?

It's OK to need help with this situation, and in my opinion, you do need the wisdom and support of your doctor to get back on track. I wish you the best.

[Vagusnervex]

Purple toes, you are right. I get anxious about this stuff because I'm in a medical field. I see how healthcare providers regard people who are prescribed controlled substances. People with scripts for narcotics who have bad intentions really have given the rest of us a bad name.

But I have decided to make an appt with my reg doc to lay it out. It really is stupid that I haven't done this yet. The adderall's benefits have diminished for a couple of years now and it's time to try something new. I don't think that just increasing the dose will make any difference. Maybe something else can be added to a smaller dose of the adderall? I'm not sure as to what the next step is. I feel worried about getting this right as I'm less than 2 weeks away from starting a crazy rigorous program.

PT, could you explain how the 90 day thing works? I'm not totally understanding that.

[Vagusnervex]

Forgot to answer the question about willpower in terms of the dose. What happened was that my school demands increased substantially and I started taking an additional 10 mg to handle my night courses. Now I've kind of plateaued on that. I don't go beyond that amount but now the 60 mg has little effect on my focusing ability.