Insurance for Newer ADHD Medication in Ontario

While this blog is intended for people of all countries and regions to learn about ADHD, I have had a number of questions from people in my own province about how their doctors can help them to get coverage for the new ADHD medications.

In Canada, we have three of the newer ADHD medications, including Strattera, Concerta and Adderall XR. I understand that Biphentin is coming imminently. In general, these medicines are about 3 times as expensive as the older medicines, Ritalin, Ritalin SR, Dexedrine and Dexedrine Spansules.

The approximate costs of these new medicines in Canada (obtained by phoning my local Shoppers Drug Mart pharmacist):

Concerta: ~$2.50 for 18 mg, $3.22 for 36 mg, ~$3.70 for 54 mg
Adderall XR: approx. $3.39 for all dose strengths (in 5 mg increments from 5 mg to 30 mg)
Strattera: approx. $4.90 for all dose strengths (10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg)

When it comes to insurance coverage, approximately 90% of private health insurance (i.e. extended health coverage from work) will cover these medicines. It is important to know that depending on the package that the employer has bought, you may not have these new medicines covered, or it may be that the insurance only covers 80% of the cost.

Regarding people who get insurance from the Government of Ontario – i.e. the Ontario Drug Benefit card (which is obtained if one is on Ontario Works, ODSP, or the child is on the ACSD) or the Trillium Drug Plan, there is no initial coverage for the newer ADHD medicines.

The Ontario Drug Benefit covers these medicines for ADHD without special application:

Ritalin
Ritalin SR
Dexedrine

The Ontario Drug Benefit covers Dexedrine Spansules if the doctor submits a relatively non complicated form to get approval.

For the newer medicines, there is a ‘Section 8′ application process for Concerta and Strattera only. It is impossible right now to get coverage for Adderall XR. A section 8 means that the government has agreed to pay for these medicines if there are very rigorous criteria met. It is my understanding that the section 8 application applies equally to the ODB, as well as the Trillium Drug program.

The criteria which must be met for coverage on the ODB of Strattera and Concerta are essentially the same. They are:

  1. A letter must be send by a doctor who is an expert in ADHD.
  2. The doctor must document the diagnosis of ADHD, which is causing impairment in the individual’s life.
  3. There has to have been an adequate medication trial of Ritalin or Ritalin SR – at an adequate dose for an adequate period of time. The doctor has to document the dosage, and the length of time the medicine was used for. The doctor has to document that there was an inadequate response to the medicine, or that there were unacceptable side effects.
  4. There has to have been an adequate medication trial of Dexedrine or Dexedrine Spansules – at an adequate dose for an adequate period of time. The doctor has to document the dosage, and the length of time the medicine was used for. The doctor has to document that there was an inadequate response to the medicine, or that there were unacceptable side effects.
  5. There has to be a 30 day trial of the new medicine (Concerta or Strattera), which is unfunded. This means that the government will not pay for the first 30 days of the medicine, but it will have to be taken to document that the new medicine works, without significant side effects. The doctor can easily give you samples of the Strattera, and can apply to get pills of the Concerta as well.

Assuming that all of the criteria are addressed properly in the letter, the ODB will get back within about 3-4 weeks with an approval letter for 6 months or 1 year of coverage of the medicine. That said, myself and my colleagues have experienced a high level of refusals even with all of the information present. Then, we just have to try again…

After the initial approval time frame, a reapplication has to be done. I am just going through my first round of reapplications, after 1 year right now, so I do not have direct experience with the ‘reapproval’ process right now (I will in a few weeks).

In any case, the situation is somewhat unfortunate that some people are unable to receive the newest treatments due to the costs involved. Hopefully this article will help people to find coverage for the newer ADHD medicines in Ontario. If you don’t live in Ontario, hopefully this article has openned your eyes to the possibility of pursuing this type of coverage in your jurisdiction.

I’d like to request that people in other provinces, states or countries share their experiences about:

  • the costs of the ADHD medicines
  • insurance coverage for ADHD medicines
  • accessibility to ADHD medicines in general

Just hit the comment button below to share your experience. Please know that I moderate all of the comments, so it will take a little bit of time until the post shows up.


Claim Your Free ADHD eBook
Signup For Dr. Kenny's weekly ADHD eNewsletter and get a free eBook:
PBOOK001shrunkendown225CroppedTransparent Insurance for Newer ADHD Medication in Ontario
ribbon blue Insurance for Newer ADHD Medication in Ontario
lock Insurance for Newer ADHD Medication in Ontario
We hate spam just as much as you

Comments

  1. Dr. Handelman,
    I have been taking Straterra since June 16, 2005. In my previous 51 1/2 years I have not felt this good, with consistent mental concentration. That’s the good news. But it was a frustrating journey with my insurer to not be deterred from taking this medication that works very well for me. My situation is in the United States.

    I was given samples of Strattera by my doctor to get started. I applied to my insurer right away. After responding really well to the medication my doctor recommended, I was disappointed to discover my insurer wanted me to jump through the hoops you describe in this post of your blog.

    I had recourse to appeal with my insurer so that I would not have to begin another medication when I was doing well on the one I was taking. I knew the alternative medication, Concerta, worked quite differently. My doctor didn’t want to appeal.

    I found another doctor. He said if I was doing well on Strattera he would not recommend I try Ritalin or Concerta. He also said he would usually begin trying people on Strattera, not the stimulants such as Ritalin, Concerta, etc. as insurers recommend due to costs. He and I agreed this was purely and simply about costs to insurers, and not what was in the best interest of the patient.

    The sad conclusion of my story makes it a story of ethics. My doctor concluded the only way to deal with the insurance industry, in this case, was to lie to them. He told me he would write out a prescription for Ritalin. He told me to not take it. He told me to get in touch with his office in a few weeks. His office would write a letter stating I had negative side affects with Ritalin and would appeal my need to take Strattera. This was to avoid my body needlessly going through predictable negative adjustments to new medication when the one I was on was working so well.

    The side story: Since the black box warning came out on Strattera my insurer has changed their policy. They now will cover Strattera without preconditions. Growing up in a medical family, I believe this is about profit margins, not what is in the best interest of the patient to receive the best therapy. I also don’t believe this a reasonable way to keep down the high costs of medications. I believe this is about the ethics of greed on many levels, and the ethics of providing optimum therapy for patients for a reasonable cost.

    My sad conclusion: I wrote to my insurer, using the appeals process in place with them, to attempt to engage them in a discussion about the ethics of the process of “step-therapy” – trying something cheaper first. Because I found them unwilling to be engaged in a discussion of ethics, and only willing to discuss dollars per treatment, I have concluded the thing to do is to tell them that the advice being passed around by doctors is to simply lie to them about their step-therapy process. Perhaps, this will give them incentive to want to enter a discussion about ethics and the cost of treatment, and allowing doctors to prescribe optimum therapy that is not simply based on profit margins.

    I commend you, Dr. Handelman, for your efforts to get out good information about ADHD through your audio newsletters and your blog. Your succinct summaries of information on different aspects of ADHD are very helpful. I have benefited greatly. Thank you very much.

    Tedd

  2. Tedd,

    I really want to thank you for taking so much time to share your experience with insurance coverage of Strattera in the US.

    Having your input, as well as all of the other great comments that we get on this blog contributes so much to people learning more about ADHD. Keep up the great work!

    A couple of comments:

    1) It doesn’t surprise me that your insurer created a similar process to get coverage for the newer medicines. While I applaud your efforts to enter into a discussion of the ethical issues, my experience is also that it is about getting the cheaper costs of the treatment.

    I will let you know that on one occassion, I had a patient that I wanted to get coverage for Concerta. To follow the protocol, I started him on Dexedrine – which he had never been on. To my surprise – he actually did better with this medicine, and continued on it, and thus the Ontario Government plan got off on a cheaper medicine. This is the only experience of this type that I can think of in my practice.

    2) Regarding a doctor’s perspective – there are two issues that you have written here – 1) one doctor didn’t want to fill out the insurance papers so you had to get a new doctor; 2) your doctor decided to lie to the insurance to get your medicine covered.

    The doctor who didn’t want to fill out your papers – this is very unfortunate. It is my belief that a doctor’s role includes being an advocate for patients – and that means filling out frustrating forms now and again. Hopefully this means that you now have a doctor who is more willing to ‘go to bat’ for you and your treatment.

    With respect to honesty and the insurance form – this is a very tricky one, and certainly one of ethics. This is something that I have never done, and don’t imagine that I would.

    Although I want to advocate for my patients as much as possible, if there is a system which needs to be followed, I follow it. I wouldn’t want to jeopardize my licence to practice medicine with a problem with my honesty. I am not trying to criticize your doctor, however the ‘standard of medical care’ is defined as what the doctor’s peers would do. It is my belief that if you asked 10 doctors if they would lie to get insurance coverage for their patient’s medicine, I would guess that only a very small percentage would say yes (if any).

    That said, in Canada, us doctors have to deal a lot less with the insurance issues than the American doctors – so I can’t really comment on their experience.

    That said, I have given prescriptions to patients and asked them to take it for a week and then let me know how it was. So, I have tried to limit the exposure to make it easier on my patients.

    Thanks again, and I hope that we get other great comments from people all over the world.

  3. Hello
    I have just recently started gving my 7 year old son Strattera. This is the first perscription and fortunately there has not been a problem, not yet anyway.
    I do however have concerns obout the medication itself. He is afraid to swallow the pill. I had to yell to get him to swallow it and that gets very frustrating and hard on him as well as myself and the rest of the family. I was told that the pill can’t be cracked in half but I’m just wondering if its just because its a capsule?? I went ahead and pulled the pill apart and mixed the powder from the pill on a spoon with some water. I’m wondering if this will have the same effect ? It seems to have started working almost 2 or 3 days after he started taking it and I would really like to continue him on it. It may seem strange that the medication would work this soon but I have seen a big change in him over the short period of time. He started taking it on Sept. 1 if my memory serves me correctly , of this year. Please take my email into consideration as I would really like to get an answer from you if you think it would be ok to break the pill open as he is refusing to take the pill whole. Thanks in advance.

  4. I was given strattera through the pharmaceutical company and although it worked for the outlaying symptoms of depression and nightmares/insomnia, it didn’t work on focus at all.

    Due to the drug card I am now on Ritalin SR. It’s horrid. Does nothing except give me headaches, “drop” and dry mouth.

    The diagnosing psych stated that if I had access to Strattera–he would have considerably increased the dosage to see the results. Due to the expense he suggested Concerta.

    I’m so desperate for relief that I am considering paying out of pocket on my meager ODSP income. I cannot tolerate any SSRI’s or Wellbutrin which is cutting down my options.

    Also, I have PTSD as well. Due to working ‘in the field’ for years, my options for psychiatric intervention are limited for privacy reasons.

    If anyone knows of a *private* psych who is OHIP covered, and has openings, who can help me with some of the emotional aspects as well as medication, I would be truly grateful.

  5. My 10-year-old son has been taking Biphentin 30 mg for 8 months. The upside:
    - the capsule can be opened and its contents sprinkled on yogourt
    - he is no longer the object of ridicule and a fun and easy target for bullies (he used to overreact to everything then get into trouble with the school principal & teachers instead of the bully)
    - he can now complete assignments and exams (he passed grades 3 and 4 because his teachers graded him on “potential” and not on school work/exams – he never finished anything)

    but the downside:
    - difficulty falling asleep
    - significant loss of appetite to the point where his pediatrician is wondering if he’s anorexic

    In Quebec, Biphentin 30 costs $71.20 for 30 capsules. 80% is reimbursed by my health coverage from work.

  6. Hi My Name Is Cameron:

    I live in Alberta, is there a “Section 8″ application process for Strattera?

    If not what current drug plans cover Strattera?

    Thanks…..

  7. I wonder if you have any info on whether Vyvanse is being considered for coverage under the Trillium/ODSP plan in Ontario. I may come back and answer this as my research progresses..;) Thanks in advance.

    Craig.

Leave a Reply