I’m pleased to inform you that as of April 1, 2009, Concerta and Adderall XR will be covered under the Ontario Drug Benefit (ODB) program.
This is a huge improvement for people who were previously not able to get coverage for these newer medications.
Who is covered under the ODB?
The Ontario Drug Benefit Program covers people who are on: Ontario Works, Ontario Disability Support Program, Assistance for Children with Severe Disabilities, or the Trillium Drug Plan.
(and if you are an Ontario family who doesn’t have insurance, please take a moment and look into the Trillium Drug Plan – if you qualify – it could get you insurance coverage).
In the past – the Ontario Drug Benefit would only cover the following medications for ADHD: immediate release methylphenidate (ritalin), Ritalin SR, and Dexedrine. The Dexedrine Spansules (the longer acting Dexedrine) were available via special application. It was generally not hard for doctors to get approval for their patients with the Dexedrine Spansules.
When the newer medications became available – i.e. Adderall XR, Biphentin, Concerta, and Strattera (listed alphabetically), they were all gradually added to the ‘Individual Clinical Review’ Process. This meant that the doctor could apply for any individual patient to get coverage. To qualify for this coverage, the patient had to have tried a methylphenidate medicine (i.e. Ritalin or Ritalin SR) and have failed it, AND he/she had to have taken Dexedrine and failed it, AND he/she had to take the newer medicine for at least 30 days (without funding) and it had to have worked well.
Even when doctors would go through this process and apply for coverage, patients were often refused coverage. This was frustrating for the patients, as well as for the doctors, and it left families without insurance coverage for the medicine that was working best for them.
I’m pleased that there has been a change in the Ontario Drug Benefit Program. As of April 1st 2009, Concerta and Adderall XR will be covered on the ODB. Unfortunately, this new coverage does not include Biphentin and Strattera. This is unfortunate, and hopefully the new coverage can be extended into the future. (Strattera and Biphentin can still be applied for through the Individual Clinical Review process).
The short message for the getting coverage for Concerta and Adderall XR is this: There is no additional paperwork needed. I will reproduce the official criteria below – so please feel free to share this information with your doctor.
The official documentation can be found here (as a PDF document – the relevant pages are pages 2 and 3).
Notes: Patients > 6 years of age diagnosed with ADHD according to DSM-IV criteria and where symptoms are not due to
other medical conditions which affect concentration, and who require 12-hour continuous coverage due to academic and/or
psychosocial needs, and who meet the following:
1) Patients who demonstrate significant and problematic disruptive behaviour or who have problems with
inattention that interfere with learning; AND
2) Prescribed by or in consultation with a specialist in pediatric psychiatry, pediatrics or a general practitioner
with expertise in ADHD; AND
3) Have been tried on methylphenidate immediate release (IR) or methylphenidate slow release (SR) or
Dexedrine IR or Dexedrine SR (Spansules), and have experienced unsatisfactory results due to poor
symptom control, side effects, administrative barriers, or societal barriers.
Administrative barriers include:
. inability of a school to dose the child at lunch;
. the school lunch hour does not coincide with the dosing schedule;
. poor compliance with noon or afternoon doses;
. the patient is unable to swallow tablets.
Societal barriers include:
. the patient or patient’s caregiver(s) has(have) a history of substance abuse or diversion of listed
. the patient or patient’s caregiver(s) is/are at risk of substance abuse or diversion of listed
The coverage is for the following doses of Concerta:
- Concerta 18 mg
- Concerta 27 mg
- Concerta 36 mg
- Concerta 54 mg
The coverage includes the following doses of Adderall XR:
- Adderall XR 5 mg
- Adderall XR 10 mg
- Adderall XR 15 mg
- Adderall XR 20 mg
- Adderall XR 25 mg
- Adderall XR 30 mg
This decision is a great step in the right direction to get the most effective medicines into the hands of people who need them. While I’m happy for Ontarians, I am also concerned that many other provinces do not have the insurance coverage that is needed. Also – we want to extend this coverage to Strattera and Biphentin.
I want to acknowledge the significant advocacy work done by CADDAC – the Centre for ADD/ADHD Advocacy Canada. This organization has been working diligently on this issue – and played a critical role. I suggest you visit their site and get involved.
Does this decision impact you or your family?
Do you live outside of Ontario, and have your own thoughts and opinions on insurance coverage – for the newer vs. the older medicines? Please shrae your comments below.