Does Blue Cross Blue Shield cover Vyvanse?

In this article:

• Does Blue Cross Blue Shield cover Vyvanse?
• Does BCBS cover generic Vyvanse?
• How much does Vyvanse cost?
• How much does Vyvanse cost with BCBS?
• How to check whether your BCBS plan covers Vyvanse
• How to save on Vyvanse

In this article

• Does Blue Cross Blue Shield cover Vyvanse?
• Does BCBS cover generic Vyvanse?
• How much does Vyvanse cost?
• How much does Vyvanse cost with BCBS?
• How to check whether your BCBS plan covers Vyvanse
• How to save on Vyvanse

The Centers for Disease Control and Prevention says an estimated 15.5 million U.S. adults have diagnosed attention-deficit hyperactivity disorder (ADHD). And for many of those adults, the hyperactivity, impulsivity, and trouble focusing it causes can derail their daily lives. That’s why many seek out medications like Vyvanse (lisdexamfetamine dimesylate). This brand-name prescription drug increases the brain’s norepinephrine and dopamine levels, improving attention and focus. But if you have Blue Cross Blue Shield (BCBS) insurance, you might wonder whether it’s covered. Here’s why some BCBS plans may cover it, while others may not. 

Does Blue Cross Blue Shield cover Vyvanse?

Sometimes. The Blue Cross and Blue Shield Association is actually a collection of independent licensees that handle insurance for their individual states. Each independent licensee of the Blue Cross has different plans. There are a lot of variables at play when it comes to prescription drug coverage, including the type of insurance (e.g., private, Medicare, or Medicaid), the formulary tier, and whether there are generic alternatives, according to Zishan Khan, MD, a psychiatrist at Mindpath Health. 

Formularies

Generic drugs and preferred brands typically receive the best coverage, while non-preferred brands might not receive coverage or may require extra information from the healthcare provider. Some plans may list brand-name Vyvanse as a preferred brand-name drug, but others may not. In cases where the BCBS formulary doesn’t include the brand-name version, they may cover generic lisdexamfetamine instead. That said, there are two other factors that can influence coverage: prior authorization and the reason for taking it.

Note: Since Vyvanse is a stimulant and a controlled substance (like Adderall), some plans may also have quantity limits, which are restrictions on the amount you can get per month.

Prior authorization

For brand-name drugs, particularly non-preferred ones, insurance plans might require proof that the drugs are medically necessary before covering them. This process is called prior authorization (or preauthorization). It typically necessitates “documentation of a formal ADHD diagnosis, often including standardized rating scales or clinical notes from the provider,” Dr. Khan says. It might also require step therapy, which is “a history of treatment trials with other stimulants and an explanation as to why they were ineffective or poorly tolerated.”

Another typical prior authorization requirement is an explanation of the drug’s medical necessity. Dr. Khan says his reasons for medical necessity often include the fact that it only requires one dose per day and has a smoother delivery and a lower abuse potential than other ADHD medications.

“Insurers will require updated clinical notes every six to 12 months to maintain approval,” Dr. Khan says. So check with your formulary and healthcare provider to understand the full extent of your plan’s prior authorization policies.

Reason for taking it

The FDA has approved Vyvanse for ADHD and binge eating disorder. When a healthcare provider prescribes it for anything else (e.g., depression or narcolepsy), it’s considered an off-label use. These uses are legal when prescribed by a healthcare provider, but they might not be covered by insurance like an FDA-approved use would.  

Does BCBS cover generic Vyvanse?

Even if your Blue Cross Blue Shield plan classifies Vyvanse as a non-preferred brand, that doesn’t mean you’re out of luck. Vyvanse is also available as a generic medication called lisdexamfetamine dimesylate, and many BCBS plans will cover generics for ADHD treatment.

“Switching to a generic can greatly reduce out-of-pocket costs, especially for families with a high deductible or limited pharmacy benefits,” Dr. Khan says. “It’s pharmacologically identical to brand-name Vyvanse. And in most patients, it is equally effective.”

Generics are essentially the same drug as their brand-name references, since the FDA requires that they use the exact same active ingredients, strength, dosage form (tablet, capsule, etc.), and routes of administration (oral, topical, etc.). In fact, studies show that generics match brand-name drugs in performance. So if your plan covers generic lisdexamfetamine, but not brand-name Vyvanse, you’ll get a virtually identical drug with possibly better insurance coverage.

How much does Vyvanse cost?

People who have prescription drug benefits might not need to pay the full price for Vyvanse. But not everyone has health insurance, and not everyone’s plan will cover it. For people paying completely out of pocket for their prescriptions, a one-month supply of Vyvanse costs about $553 for 30, 30 mg capsules. Over the course of a year, that comes to over $6,600. Prices fluctuate and vary by pharmacy. 

The generic version of Vyvanse, lisdexamfetamine dimesylate, costs an average retail price of $443 for 30, 30 mg capsules. 

How much does Vyvanse cost with BCBS?

What you’ll pay for Vyvanse with BCBS depends on the details of your prescription drug plan—whether it covers Vyvanse on its formulary and what tier it is on. Drugs in the generic or preferred brand tiers typically receive more comprehensive coverage than those in the non-preferred and specialty tiers. So on some BCBS plans, your out-of-pocket costs might be $0 for generic lisdexamfetamine, and you might have higher copays for brand-name Vyvanse.

It’s hard to say how much, exactly, you’ll end up paying. However, a 2022 employer health benefits survey from KFF showed that the average copay across insurance company plans with three or more tiers is $11 for first-tier drugs, $37 for second-tier drugs, $67 for third-tier drugs, and $116 for fourth-tier drugs.

How to check whether your BCBS plan covers Vyvanse 

Since Blue Cross Blue Shield is a network of individual companies, it doesn’t have one overarching website that houses every plan’s formulary. Instead, you’ll need to find your specific formulary on that company’s website. For example, if you have Blue Cross Blue Shield of Michigan, go to its website, click the tab on top for “Individuals,” then click “Resources,” scroll down, and you’ll be able to search by drug list.

Each website is slightly different, and some may require you to log in to your member account before you can see your formulary. But in most cases, you should be able to find them under a tab titled “Resources” or “Prescription Drugs.” You might also have success searching “Blue Cross Blue Shield drug lists” plus the name of your state.

But if you’d rather avoid the website altogether, you can always call the member services phone number printed on the back of your health insurance card. Make sure you have your plan ID and group number ready, since they’ll likely need that info.

How to save on Vyvanse

Blue Cross Blue Shield plans can help you save a lot of money on prescription medications—but so can some other resources. In fact, there are plenty of ways to save on Vyvanse, even if you don’t have insurance coverage.

One of the most reliable is using Vyvanse coupons from SingleCare. These are completely free and accepted at pharmacies across the country. All you have to do is present your coupon or your SingleCare discount card when you pick up your prescription. Instead of paying $553 for 30, 30 mg brand-name Vyvanse tablets, these coupons can knock the price down as low as $65 for the generic version. However, you can’t use these savings on top of insurance coverage, so you’ll have to see which discount is better.

If you’re trying to get insurance coverage for Vyvanse, Dr. Khan recommends asking your prescribing healthcare provider to “submit a thorough prior authorization, which includes your diagnosis, medication history, and rationale for selecting Vyvanse. The less back and forth with denials and appeals, the more likely an approval will be made.”