Ask the Experts

Is My Insurance Company Required to Cover Specific ADHD Medications?

“My pharmacy plan is taking Concerta off the list of medications they will cover,” one reader tells us. “The company suggests my son use Ritalin, which he tried years ago without success. Do I have legal recourse to make the plan cover Concerta?”

You may. Before taking the insurance company to court, go through the company’s internal administrative process. Have your doctor speak with the insurance company and explain that Ritalin did not work for your son’s attention deficit hyperactivity disorder (ADHD) and that Concerta had been prescribed instead. Also have the doctor draft a letter and mail or fax it to the company. If the company still refuses to cover the medication, file a formal appeal with the company. Keep copies of all the letters, along with copies of correspondence from your insurance company, in a file.

If the company still doesn’t cover the medication, and if you find the company’s policy contradicts the law or its own regulations, file a complaint with your state’s Department of Insurance. Contact an attorney who specializes in health insurance law to advise you on how to proceed. On the federal level, the Mental Health Parity and Addiction Equity Act (MHPAEA) requires that insurance companies apply the same dollar and treatment limits to mental health conditions that they apply to physical health conditions. Talk with your attorney about possible violations of this law.