Navigating Level 2 Appeal?
28/USA-NJ, on Horizon BCBS NJ Omnia Gold w/ Blue Card (Marketplace Exchange)
Background: I was diagnosed with ADD-PI in 2003 at 9 years old. I was briefly medicated with Concerta and failed since I maxed out on the dosages before I was able to see any effect from the medication. I continued through school unmedicated until college when I finally was struggling enough to try medication on my own accord. My parents didn’t believe in my ADHD struggles as a kid and just basically forced me to brute force my way through school with double-textbooks and extended time on exams. However, once I got to college and was put on medication it was a huge difference. I graduated college, moved cross-country and got a job where I was on Adderall XR 30mg/daily with a 10mg IR booster (as needed), eventually I swapped to Vyvanse 50mg out there as it lasted me 14 hours which covered me from my morning through evening classes. I spent 4 years in Minnesota, 2 of those years I was on Vyvanse without issue. I relocated back to New Jersey to begin grad school which forced me to swap insurance and lose my doctors out in Minnesota. The swapping of insurance and doctors has left me in a struggle. I get about 6 hours of working time with Adderall XR 30mg on a good day. My local GP wrote the Vyvanse script and insurance denied it saying that I have to go through 2 generics with same release mechanisms before they’d consider allowing me the Vyvanse. I’m a full-time grad student, I need to be able to do my work. Insurance denied the first appeal where I had included my RX history that included the switch from Adderall XR to Vyvanse and my disability accommodations letter which had stated I was stable on Vyvanse. I’m now forced to be filing a Level 2 Appeal and I’m not sure what to do. I don’t know what I should be sending in for the Level 2 Appeal to push them to put me back on the Vyvanse.
Anyone been forced to do a level 2 appeal with insurance and win?
Tl;dr: Relocation and insurance swaps has forced me off Vyvanse, which was the medication I was best managed on. Being forced on generic medication that is not cutting it while I fight the appeal that I don’t know how to win. Currently waiting to get in with a psychiatrist, GP is only able to write the generic and doesn’t want to handle the ADHD medications. I submitted my RX records from 2019 through 2022 from Minnesota which shows the swap of Adderall XR to Vyvanse in addition to a letter from my physician to my grad school stating my current regiment and it’s effectiveness + what accommodations I needed. Insurance then responded that they “are not obligated to process it at this time” and to “file a level 2 appeal and contact DOBI for assistance.”
Timeline: 2004-DX’d -> 2006 trialed on Concerta (Age 12) and discontinued -> 2014 started on Adderall XR -> 2017 swapped Adderall to Vyvanse back to Adderall d/t study abroad in Japan -> 2018 adderall XR 30 + 10mg booster and relocated to Minnesota-> 2020 swapped Vyvanse full-time -> 2022 -> relocated back to NJ and forced off Vyvanse by insurance.
Insurance requires 2 generics with same release mechanism to be tried unless I have FDA contraindications, side effects, or allergies within 90 days… I don’t have side effects other than the crashing on Adderall, the hungry, annoyed at everything, exhaustion when it wears off… which to my knowledge doesn’t count as “true” side effects as it’s a withdrawal. I’m tachycardic on all stimulants and am on Amlodipine anyway for Reynauds so I don’t think I have a leg to stand on arguing the side effects or contraindications. I’m also on Wellbutrin XL for depression which stimulants interact with and increase risk of Serotonin Syndrome, which again, I don’t think will make much of a difference.
