*UPDATE POST 69* Medication no longer covered on insurance formulary

[starry_solo]

Call Costco, Sams club, or BJs. You don't need to be a member to use their pharmacy.

Call them directly for a quote on your prescription (generic or brand), don't rely on GoodRX to check.

 

[Jeff_G]

Been here as well, this drug has been a absolute life changer for my son. The non authorized generics did not work and are not the same release mechanism. So that leaves us with the name brand and authorized generic. As others have said United and other insurance carriers stopped covering the authorized generic but do cover the brand name. For those of us on high deductible plans that means we pay the full price of the name brand, and this stings. I have used good RX which as your pointed out would NOT then deduct from your deductible. This is something to weigh out.

This drug is even more of a pain because its a controlled substance, and there were (still are) non authorized generics that did not work being substituted for the name brand. Mail ordering a 90 day supply I found was a total gamble as to which manufacturers drug you would get.

So my solution is to have my son's DR write a 30 day prescription for Concerta which I can then take to various pharmacies and ask which manufacturer I will get and if they / my insurance will allow the authorized generic. I do all this BEFORE I hand over the written prescription to the pharmacist that way I can walk away and try a different pharmacy.

Its a HUGE pain, however the drug has made such a huge difference in my son's life.

 

[dreiwhit]

As others have said United and other insurance carriers stopped covering the authorized generic but do cover the brand name.

I'd love to know why they did this. Everything that I ever read said generics were cheaper than name brand. I can't see why insurance companies would stop covering generics but allow name brand?

And, I really hope it isn't a trend. A couple of my meds went generic earlier this year, so instead of $50 a month, i'm spending $14!

 

[Jeff_G]

I believe the insurance companies are responding to the fact that the FDA downgraded several of the generic versions of concerta and reclassified them as no longer automatically substitutable for the name brand. This was done after numerous complaints to the FDA by users of these generic versions of the drugs as well as the efforts of many physicians. It was a huge victory for those that had problems with the generic versions of the drug. I think many insurance carriers in response the to the FDA downgrade just stopped covering "generics" for concerta.

The authorized generic concerta is a little different then many other generics in that the drugs is produced by the name brand manufacturer on the same production line, they then sell it to the generic pharmaceutical company at a reduced cost, who then sells the generic to pharmacies.

 

[LoveBWVVBR]

Been here as well, this drug has been a absolute life changer for my son. The non authorized generics did not work and are not the same release mechanism. So that leaves us with the name brand and authorized generic. As others have said United and other insurance carriers stopped covering the authorized generic but do cover the brand name. For those of us on high deductible plans that means we pay the full price of the name brand, and this stings. I have used good RX which as your pointed out would NOT then deduct from your deductible. This is something to weigh out.

This drug is even more of a pain because its a controlled substance, and there were (still are) non authorized generics that did not work being substituted for the name brand. Mail ordering a 90 day supply I found was a total gamble as to which manufacturers drug you would get.

So my solution is to have my son's DR write a 30 day prescription for Concerta which I can then take to various pharmacies and ask which manufacturer I will get and if they / my insurance will allow the authorized generic. I do all this BEFORE I hand over the written prescription to the pharmacist that way I can walk away and try a different pharmacy.

Its a HUGE pain, however the drug has made such a huge difference in my son's life.

That run around to make sure you get the correct generic is a huge pain but it's so necessary. In our area Walgreens always carries the authorized generic though, so I only go there now. I never gambled with mail order because, like you said, the non-authorized generics don't work the same and we can't run the risk that we end up with 90 days of one of those. As it is, AFTER they couldn't dispense those for Concerta I had a large chain pharmacy dump 30 days worth of the non-authorized generic on me. I was furious, and I did get it rectified.

I believe the insurance companies are responding to the fact that the FDA downgraded several of the generic versions of concerta and reclassified them as no longer automatically substitutable for the name brand. This was done after numerous complaints to the FDA by users of these generic versions of the drugs as well as the efforts of many physicians. It was a huge victory for those that had problems with the generic versions of the drug. I think many insurance carriers in response the to the FDA downgrade just stopped covering "generics" for concerta.

The authorized generic concerta is a little different then many other generics in that the drugs is produced by the name brand manufacturer on the same production line, they then sell it to the generic pharmaceutical company at a reduced cost, who then sells the generic to pharmacies.

That downgrading happened in like Nov. of 2014 though, didn't it? It was a huge victory, as it eliminated the generic Russian roulette at the pharmacy. I am doubtful as to that being the reason that it's suddenly dropped off the insurance formulary. My guess is that it's still very expensive even as a generic and they want to push insurance holders to ask their doctors for cheaper alternative drugs.

 

[lost*in*cyberspace]

I am feeling very happy with my medical insurance after reading this. We only have to pay $46.00 for a 90 day supply of a non-formulary drug, $0 for a generic and $16 for a brand name (Johns Hopkins US Family Health Plan).

 

[Jeff_G]

That run around to make sure you get the correct generic is a huge pain but it's so necessary. In our area Walgreens always carries the authorized generic though, so I only go there now. I never gambled with mail order because, like you said, the non-authorized generics don't work the same and we can't run the risk that we end up with 90 days of one of those. As it is, AFTER they couldn't dispense those for Concerta I had a large chain pharmacy dump 30 days worth of the non-authorized generic on me. I was furious, and I did get it rectified.



That downgrading happened in like Nov. of 2014 though, didn't it? It was a huge victory, as it eliminated the generic Russian roulette at the pharmacy. I am doubtful as to that being the reason that it's suddenly dropped off the insurance formulary. My guess is that it's still very expensive even as a generic and they want to push insurance holders to ask their doctors for cheaper alternative drugs.

Yah getting 90 days of an expensive controlled substance drug that doesn't work was NO fun.

Yes the downgrade was November of 2014, then one of the generic manufacturers sued the FDA over the downgrade, in July of 2015 they lost the suit.


Funny antidote, my wife works for a hospital, so she took the pills to her pharmacist for destruction. This medication was supposed to last 12 hours in the body. The pharmacist placed these pills in a bowl with water as per their destruction protocol for the medicine. Within 15 minutes all of the pills had completely dissolved. He was shocked and said they would have dissolved even faster in stomach acid.

 

[kerplop]

As an adult with ADD, I take Vyvanse and it's not cheap either. Even with insurance it's $50 a month. Do they have any coupons for name brand Concerta? You can also ask your doctor about free trials. They absolutely do have them for controlled substances, like ADD/ADHD meds and I know because I got one my first month. Basically it's a coupon you take in to the pharmacy, they process it along with your scrip, and you get a month free. I don't know how often you can do that, but it might be a good stop-gap, if your ped will do it.

 

[disneymomto5]

I feel your pain. We've lost our insurance and our jobs and my daughters ADHD medication is $293 a month. When you have no job, that's a lot.......We still have figured out what to do.

 

[tink2dw]

Our state Gov. had cut the State Health Care.

I was one, that lost the State Health Care. That meant I had no drug coverage. I Have seizer disorder, left over by Brain Tumor, that calcified. My seizers put me in the hospital ever 3 to 4 months. I was in hospital two Christmas in row. not nice.

I take one seizer pill, 2 in the morning, and 2 at night. At the price of $1400.00 a month. The other is one is 1 in morning, and 1 at night. At the price of $750.00. Hubby and me are both disable. He was award disability payment. We had choice pay rent and electricity or pills.

My Hubby had a made a call to the company of the pill that was $1400.00 they gave him 3 number to call. They were 2 party agencies. He found a company that Said would helps us. We had fill out their form, take the form to the Dr. to fill out his part. Then Fax the forms back to them. They would give us 3 month of pills for $50.00!!!! We did the same with different company for the $750.00. They sent it every month at no cost!!!! They did this for 2 year. Until I was able to qualify for Obama Care and get drug coverage, again.

This is tell you don't give HOPE!! Call, call, call. Google!! Their is someone out there to Help you and your child!!! Don't give up!!
Here is a little pixie for you!!
*~~~~~~~~~~~~~~~~~~~*~~~~~~~~~~~~*~~~~~~~~~~*~~~~~~~~~~~~~~~~*

 

[LoveBWVVBR]

I feel your pain. We've lost our insurance and our jobs and my daughters ADHD medication is $293 a month. When you have no job, that's a lot.......We still have figured out what to do.

In this case I think GoodRx is worth a look. They bring the Concerta cost down to $104/month for me at Walgreens apparently.

Also, can you get state insurance for your daughter since you lost your jobs? If so, maybe it will just be covered under the insurance.

 

[LoveBWVVBR]

As an adult with ADD, I take Vyvanse and it's not cheap either. Even with insurance it's $50 a month. Do they have any coupons for name brand Concerta? You can also ask your doctor about free trials. They absolutely do have them for controlled substances, like ADD/ADHD meds and I know because I got one my first month. Basically it's a coupon you take in to the pharmacy, they process it along with your scrip, and you get a month free. I don't know how often you can do that, but it might be a good stop-gap, if your ped will do it.

I will call DD's ped. and ask about this today. I've only ever found the generic Concerta at the pharmacies around here though. None stock the brand name. I guess I'd have to have it ordered and then use the coupon? Like you said, I wonder how often that could be done.

 

[Eastern]

I was going to come on here and ask if anyone had experience with GoodRx. If they are just quoting the price of the meds at Walgreens, what I am getting for a quote (also around $104) is wrong. We fill our prescription there every month and it's way more than that. Maybe that is some sort of discount they give with GoodRx though. I called the pharmacy and they need to run the prescription with GoodRx to see what it will cost, so I will try this once I have the prescription for the next refill in hand.

I have a lot of experience with GoodRx. I was paying a lot for one med at Target then I brought in the GoodRx coupon. The pharmacist said, 'we get coupons all the time, and they don't always work', but she did run it through, and it did work. I was very surprised that I was not automatically offered the cheaper price by Target to begin with, but that's how it goes in the prescription business. I was paying even more at Wegman's. (Wegman's, >$100 per month, Target, >$35 per month, GoodRx, $15 per month, Sam's Club with plus membership, $8 per month).

Since Target Rx was acquired by CVS, prices have gone up. The GoodRx prices in the recent past were not being honored by Target. I left them and went to Sam's Club. If you join with plus membership, a lot of the drugs are very low cost if you get them monthly. Generic Concerta is not listed but you may have to ask for any controlled drug prices.
http://resources.samsclub.com/healt...dat16|ExtraValueDrugList_PDF_English_DrugName

This may not help OP but may help others.

Also: GoodRx will answer emails promptly and give you advice if a pharmacy is giving you trouble. When you look up your drug, make sure the dosage is correct, and look at different amounts (for ex a lot of the prices are for 90 tabs vs 100). When you are ready to fill your Rx, print out the coupon that same day, as the prices can change daily. Have your pharmacist run it through before they automatically reject it. Again, this may not help OP, but may help others.

Good luck to everyone; it's only going to get worse.

 

[dreiwhit]

Good luck to everyone; it's only going to get worse

Sadly, I'm afraid you are right. For us, insurance started getting worse about 4 years ago and has only gone down hill since then....

 

[MommaBerd]

I'd love to know why they did this. Everything that I ever read said generics were cheaper than name brand. I can't see why insurance companies would stop covering generics but allow name brand?

And, I really hope it isn't a trend. A couple of my meds went generic earlier this year, so instead of $50 a month, i'm spending $14!

I am not a pharmacist, but this is what my doctor explained to me...really simplified. Generics are not EXACT replicas of the name brand, they have tolerance levels within which to operate. So, if the one of the ingredients is more expensive or less available, Generic A can reduce its quantity to the lower end of the tolerance level. Generic B may (for whatever reason) be operating on the upper end of the tolerance level for same ingredient. So let's say, one month you get Generic A and the next month you get Generic B. While both are within the federal tolerance guidelines, the swing difference between the two could be a significant difference to your body.

I think this is the case in brain chemistry medications. I am in the same boat as the PP with her seizure medications. It is possible that if someone with controlled seizures gets just a little less medication (lower end of tolerance level), over time, it may result in breakthrough seizures. My guess is that it's the same with *certain types* of depression, ADHD, bipolar, etc. The brain does not like to have its chemistry messed with!

I am *very* thankful to have medication that has controlled my seizures for 8 years, but I do wish it were less expensive. I am a capitalist at heart, but when I've been on a medication for that long (and it has been around longer) and THEY KEEP RAISING PRICES, it's a little disconcerting. But, that seems to be par for the course of our broken healthcare system.

 

[Jeff_G]

I am not a pharmacist, but this is what my doctor explained to me...really simplified. Generics are not EXACT replicas of the name brand, they have tolerance levels within which to operate. So, if the one of the ingredients is more expensive or less available, Generic A can reduce its quantity to the lower end of the tolerance level. Generic B may (for whatever reason) be operating on the upper end of the tolerance level for same ingredient. So let's say, one month you get Generic A and the next month you get Generic B. While both are within the federal tolerance guidelines, the swing difference between the two could be a significant difference to your body.

Concerta is an exception to this rule, the authorized generic is actually manufactured by the same company that produces the name brand, its the exact pill. In this case the name brand manufacturer is selling the pill to the generic distributor at a reduced cost. Drug manufacturers will sometimes do this on a medication in order to stave off a true generic from emerging onto the market.

Drug manufacturers spend tons of money researching, and testing drugs all before they can sell it. They then need to recoup the expense of all that research and testing. So in a way the drug you are buying now funds the next generation of drug research.

 

[MommaBerd]

Concerta is an exception to this rule, the authorized generic is actually manufactured by the same company that produces the name brand, its the exact pill. In this case the name brand manufacturer is selling the pill to the generic distributor at a reduced cost. Drug manufacturers will sometimes do this on a medication in order to stave off a true generic from emerging onto the market.

Drug manufacturers spend tons of money researching, and testing drugs all before they can sell it. They then need to recoup the expense of all that research and testing. So in a way the drug you are buying now funds the next generation of drug research.

My response was not specifically geared toward the Concerta authorized generic, but rather to the general question as to why insurance companies would stop covering generics and only cover brand.

And I totally get the cost of R&D, but I'm also not naive to the fact that pharma companies are for-profit organizations who are responsible to their shareholders for a return on their investment. Again, I am very pro-capitalism, but I'm really beginning to struggle with the way the cost of healthcare is spinning out of control. But, now I'm getting way off topic.

 

[PatMcDuck]

My (adult) son also upset over the Vyvanse medication. Also suddenly has been dropped. He has even tried switching his insurance coverage to get it covered. Has used the manufacturer coupons in the past, too. They switched him to another medication, and he says it is bad because it hits him all too much at once, and does not last as long. He has been on same Vyvanse dose for years, and did not want any sort of increase. I forget what he was paying per month (does not live here with me), but it was hundreds of $$.

 

[dhardawa]

I'd love to know why they did this. Everything that I ever read said generics were cheaper than name brand. I can't see why insurance companies would stop covering generics but allow name brand?

And, I really hope it isn't a trend. A couple of my meds went generic earlier this year, so instead of $50 a month, i'm spending $14!

My pharmacist said the insurance companies get a kick back and it's likely the Concerta manufacturer is giving them more.

 

[dhardawa]

I will call DD's ped. and ask about this today. I've only ever found the generic Concerta at the pharmacies around here though. None stock the brand name. I guess I'd have to have it ordered and then use the coupon? Like you said, I wonder how often that could be done.

I have to have it ordered to get the name brand, but since that's what the insurance covers, that's what I do.