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:
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:
- A letter must be send by a doctor who is an expert in ADHD.
- The doctor must document the diagnosis of ADHD, which is causing impairment in the individual’s life.
- 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.
- 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.
- 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.