No ADHD in Europe means no pharma coverage in US?
June 20, 2015 9:01 AM Subscribe
Last night when I picked up my and my adult son's prescriptions for ADHD meds, I groused that the insurance company didn't consider them maintenance meds. Consequently I have to pay full price until I meet my deductible. The pharmacy employee (not a pharmacist) told me it was because there is no ADHD in Europe.
Her reasoning was that since no one in Europe has the disorder, my insurer can't justify covering the meds. I read this article, so I get that there's resistance to the diagnosis, but what does that have to do with Aetna, here in the US? Was she right or confused or what? I actually felt a little judged, like it was being implied that I didn't really have ADHD either, which I assuredly do.
To be clear, I'm not interested in diagnosis rates in Europe, I'm looking for their impact on MY health insurance.
Her reasoning was that since no one in Europe has the disorder, my insurer can't justify covering the meds. I read this article, so I get that there's resistance to the diagnosis, but what does that have to do with Aetna, here in the US? Was she right or confused or what? I actually felt a little judged, like it was being implied that I didn't really have ADHD either, which I assuredly do.
To be clear, I'm not interested in diagnosis rates in Europe, I'm looking for their impact on MY health insurance.
This has nothing to do with Europe. It is simply a fact of health insurance. You are responsible for paying for all medical costs, including prescriptions, until you have exceeded your deductible. There are some exceptions for preventative care such as immunizations and annual exams, but not prescriptions.
Maintenance medications have no special exemption regarding deductibles. It simply means that you are permitted to purchase a 90-day supply instead of the standard 30-day supply at one time.
posted by JackFlash at 9:19 AM on June 20, 2015 [4 favorites]
Maintenance medications have no special exemption regarding deductibles. It simply means that you are permitted to purchase a 90-day supply instead of the standard 30-day supply at one time.
posted by JackFlash at 9:19 AM on June 20, 2015 [4 favorites]
There was a recent (in the last week or so) obnoxious article going around Facebook about how ADHD doesn't exist in France because French people actually care about their children's wellbeing (the linked rebuttal from a French psychiatrist didn't make the rounds, strangely enough). My guess is that the employee read that, made some weird illogical conclusions, and said something that's not true.
posted by jaguar at 9:41 AM on June 20, 2015 [8 favorites]
posted by jaguar at 9:41 AM on June 20, 2015 [8 favorites]
I think the pharmacy employee was speaking from her own personal feelings or ill-researched "knowledge" of ADHD and the ADHD pharmaceutical industry / the health insurance industry.
Her opinion does not matter, but what does matter is what your Aetna policy states. Call them and ask why the ADHD medications are not included in the formulary.
Depending on what medications you take, you may want to look into whether or not the brand-name suppliers of said medications offer a discounted rate if your health insurance does not cover any or most of the cost. Also, ask your prescribing doctor if they have any deductible reduction cards (which they often receive from the pharmaceutical company sales reps) that would decrease the amount you have to pay. Sometimes these don't apply if the cost of the drug is more than X amount (which could be the case if you're being told by your health insurance that you have to pay full price) but you don't know until you ask.
I really think the "no ADHD in Europe" as an explanation for your health insurance's refusal to pay is a red herring. That is, again, why I think the pharmacy employee was just talking out her you-know and should be ignored. I'll reiterate what saeculorum said above: "Also to be clear, I can almost guarantee you the reason Aetna makes any particular decision (not just your particular question) is to maximize their profit and minimize their expenditures. Aetna doesn't particularly care whether ADHD does or doesn't exist as a disorder; they care what the expected costs associated with coverage are."
Bingo.
Then again, I am not sure what Aetna plan you have, or if it is offered through your employer or a spouse's employer. My sister has Aetna through her employer (a major big box store) and they are great about paying for her ADHD meds - her co-pay on the brand name ones are less than $15! Meanwhile, I have Kaiser Permanente and I pay $50 a pop for my medically-necessary brand name ADHD/antidepressant meds, because KP won't cover any brand name meds if there is a generic available.
posted by nightrecordings at 10:08 AM on June 20, 2015 [1 favorite]
Her opinion does not matter, but what does matter is what your Aetna policy states. Call them and ask why the ADHD medications are not included in the formulary.
Depending on what medications you take, you may want to look into whether or not the brand-name suppliers of said medications offer a discounted rate if your health insurance does not cover any or most of the cost. Also, ask your prescribing doctor if they have any deductible reduction cards (which they often receive from the pharmaceutical company sales reps) that would decrease the amount you have to pay. Sometimes these don't apply if the cost of the drug is more than X amount (which could be the case if you're being told by your health insurance that you have to pay full price) but you don't know until you ask.
I really think the "no ADHD in Europe" as an explanation for your health insurance's refusal to pay is a red herring. That is, again, why I think the pharmacy employee was just talking out her you-know and should be ignored. I'll reiterate what saeculorum said above: "Also to be clear, I can almost guarantee you the reason Aetna makes any particular decision (not just your particular question) is to maximize their profit and minimize their expenditures. Aetna doesn't particularly care whether ADHD does or doesn't exist as a disorder; they care what the expected costs associated with coverage are."
Bingo.
Then again, I am not sure what Aetna plan you have, or if it is offered through your employer or a spouse's employer. My sister has Aetna through her employer (a major big box store) and they are great about paying for her ADHD meds - her co-pay on the brand name ones are less than $15! Meanwhile, I have Kaiser Permanente and I pay $50 a pop for my medically-necessary brand name ADHD/antidepressant meds, because KP won't cover any brand name meds if there is a generic available.
posted by nightrecordings at 10:08 AM on June 20, 2015 [1 favorite]
This has nothing to do with Europe. It is simply a fact of health insurance. You are responsible for paying for all medical costs, including prescriptions, until you have exceeded your deductible. There are some exceptions for preventative care such as immunizations and annual exams, but not prescriptions.
This is not how health insurance works. I mean, maybe some plans do, but my prescriptions are not subject to the deductible (and have no separate deductible). It sounds like the OP's plan subjects some prescriptions to the deductible and not others.
posted by hoyland at 10:14 AM on June 20, 2015
This is not how health insurance works. I mean, maybe some plans do, but my prescriptions are not subject to the deductible (and have no separate deductible). It sounds like the OP's plan subjects some prescriptions to the deductible and not others.
posted by hoyland at 10:14 AM on June 20, 2015
There was a recent (in the last week or so) obnoxious article going around Facebook about how ADHD doesn't exist in France
Looking at the article, it's actually from a couple years ago, but it looks like a couple clickbait sites reposted it at the end of May.
posted by jaguar at 11:10 AM on June 20, 2015
Looking at the article, it's actually from a couple years ago, but it looks like a couple clickbait sites reposted it at the end of May.
posted by jaguar at 11:10 AM on June 20, 2015
Looking at the article, it's actually from a couple years ago, but it looks like a couple clickbait sites reposted it at the end of May.
It's also totally untrue because I know two people personally who have been diagnosed by their doctors with ADHD and are being treated for it. (French doctors, in France.)
Check with your insurance company.
posted by fraula at 12:02 PM on June 20, 2015 [1 favorite]
It's also totally untrue because I know two people personally who have been diagnosed by their doctors with ADHD and are being treated for it. (French doctors, in France.)
Check with your insurance company.
posted by fraula at 12:02 PM on June 20, 2015 [1 favorite]
"No ADHD in Europe" is clearly bonkers, because otherwise the NHS wouldn't talk about how to get treatment ("ADHD is the most common behavioural disorder in the UK").
posted by EndsOfInvention at 12:05 PM on June 20, 2015 [1 favorite]
posted by EndsOfInvention at 12:05 PM on June 20, 2015 [1 favorite]
Sometimes it is a weird combination of things like meeting deductable and specific coverage. Same thing happened with my mother's last insurance plan where she had to pay full price for brand name Adderall XR and could only get 30 pills, but it did count towards her deductable if she does it that way. The generic doesn't count. It was insane. Once her deductable was met they'd have covered 50% of the brand name.
It is also insane that on my completely different coverage I had to switch from cheap generic guanfacine to Intuniv because it costs them more as I still have the same copay!
I'm pretty sure that what we pay for here has absolutely nothing to do with whether or not ADHD is considered a diagnosis in some other country. It has everything to do with insurance and drug companies making more money.
posted by monopas at 12:13 PM on June 20, 2015
It is also insane that on my completely different coverage I had to switch from cheap generic guanfacine to Intuniv because it costs them more as I still have the same copay!
I'm pretty sure that what we pay for here has absolutely nothing to do with whether or not ADHD is considered a diagnosis in some other country. It has everything to do with insurance and drug companies making more money.
posted by monopas at 12:13 PM on June 20, 2015
Response by poster: I know for certain that NONE of the ADHD drugs are considered "preventative." They aren't on the list at all. Neither is my Lithium...now there's a preventative drug if ever there was one. So until I reach my deductible I will pay full price. Last month they were free, now we're in a new insurance year, so the price is back up. I am resigned to that fact. I don't think there's anything I can do, we just have shitty insurance. I was just wondering if there was any truth to this woman's statement. It sounds like maybe she heard that Adderall isn't approved in Europe and extrapolated this theroy. It seems like she spoke waaayy out of turn. I am friendly with the Pharmacist, so I may say something to him. She really did sound judgmental, and that's not what you need to get with your meds.
posted by Biblio at 12:15 PM on June 20, 2015
posted by Biblio at 12:15 PM on June 20, 2015
Response by poster: As a data point - we have this insurance through my husband's job at a a major pharmacy chain. The very one where I heard this theory. I work part-time, so no other insurance options.
posted by Biblio at 12:17 PM on June 20, 2015
posted by Biblio at 12:17 PM on June 20, 2015
I was just wondering if there was any truth to this woman's statement. It sounds like maybe she heard that Adderall isn't approved in Europe and extrapolated this theroy.
European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD, published online 2010 September 3.
posted by fraula at 12:25 PM on June 20, 2015 [2 favorites]
European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD, published online 2010 September 3.
The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.EU Regulators Okay ADHD Drug Similar to Adderall XR, May 2014.
posted by fraula at 12:25 PM on June 20, 2015 [2 favorites]
Of course there is ADHD in Europe. In the UK, if you have an ADHD diagnosis, you must notify the driving license authority.
posted by tel3path at 1:35 PM on June 20, 2015 [1 favorite]
posted by tel3path at 1:35 PM on June 20, 2015 [1 favorite]
Working in a Northern European country since '99 in mental health care for adults 18+: we recognize, diagnose and treat (medication and behavioral therapy) AD(H)D. No question about it.
Maybe for children there is a somewhat more conservative (holding back) guideline for medication than in the US (but that could be a cultural misconception, and I could not say, from my position). Both medication and behavioral treatment for AD(H)D are covered in our basic insurance policies, for adults and children (with a yearly deductible of 375 euros for everyone).
Here's the national guideline for diagnosis and treatment in my country (sorry, not in English) . But google guidelines Europe ADHD and you will find much more, in English even.
posted by Dutchmeisje at 5:23 PM on June 20, 2015
Maybe for children there is a somewhat more conservative (holding back) guideline for medication than in the US (but that could be a cultural misconception, and I could not say, from my position). Both medication and behavioral treatment for AD(H)D are covered in our basic insurance policies, for adults and children (with a yearly deductible of 375 euros for everyone).
Here's the national guideline for diagnosis and treatment in my country (sorry, not in English) . But google guidelines Europe ADHD and you will find much more, in English even.
posted by Dutchmeisje at 5:23 PM on June 20, 2015
Adhd exists, however, your med might not be available here, frex Adderall.
On preview I see there's something similar bein made available, must go read more!
posted by Iteki at 9:16 AM on June 21, 2015
On preview I see there's something similar bein made available, must go read more!
posted by Iteki at 9:16 AM on June 21, 2015
NONE of the ADHD drugs are considered "preventative."
In your initial post, you said the ADHD drugs are not considered 'maintenance medications.' But in your follow up post, you used the term 'preventative'. I think that's where the misunderstanding is.
If your insurance covers medications that are used for preventative purposes, but not those used for treatment of a condition, then it makes sense that ADHD drugs and drugs for bipolar disorder are not covered. You already have these conditions. You are thinking of "preventative" as meaning "these medications prevent me from experiencing symptoms of my illness", but what it means in this context is "a preventative medication is one that prevents an illness from occurring."
posted by treehorn+bunny at 8:23 PM on June 21, 2015
In your initial post, you said the ADHD drugs are not considered 'maintenance medications.' But in your follow up post, you used the term 'preventative'. I think that's where the misunderstanding is.
If your insurance covers medications that are used for preventative purposes, but not those used for treatment of a condition, then it makes sense that ADHD drugs and drugs for bipolar disorder are not covered. You already have these conditions. You are thinking of "preventative" as meaning "these medications prevent me from experiencing symptoms of my illness", but what it means in this context is "a preventative medication is one that prevents an illness from occurring."
posted by treehorn+bunny at 8:23 PM on June 21, 2015
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For what it's worth, it seems that at least some Aetna policies and at least some Blue Cross/Blue Shield policies (neither of which is likely to be representative of your policy) cover a subset of ADHD medication for maintenance. You may consider talking to your prescribing doctor about switching to one of those covered drugs, which is an entirely appropriate request to your doctor. From the perspective of the insurer, if all things are equal (which they rarely are), they want their customers to use the cheapest drug possible for long term care, which is why insurers are incentivized to keep the list of covered maintenance drugs small.
To be clear, Aetna would never publicly disclose their reason for making any particular coverage choices in cases where the treatment is proven effective. Also to be clear, I can almost guarantee you the reason Aetna makes any particular decision (not just your particular question) is to maximize their profit and minimize their expenditures. Aetna doesn't particularly care whether ADHD does or doesn't exist as a disorder; they care what the expected costs associated with coverage are. This is why you sometimes see insurance companies covering what to many people are sham treatments (like chiropractic) - if you pay for it, the insurance company will cover it - and why you sometimes see insurance companies covering what to many people are effective (but costly) therapies - because the insurance company doesn't care about efficacy, they care about the cost of those therapies.
posted by saeculorum at 9:18 AM on June 20, 2015 [3 favorites]