If you’ve had problems finding a medication for ADHD that you can afford, you’re not alone. In years past generic medications were equivalent to the name brand and were always a lot cheaper.
In recent years many new versions of methylphenidate (ritalin) and amphetamines (adderall) have come on the market and generic versions of many of the older medicines have become available.
The FDA has rules that generic medications must have the same amount of active ingredient and be available in the same forms (pill vs liquid) as the original medication. They can often be sold at a much lower cost because the company does not need to spend money researching and developing the medicine. They also offer competition to the original company, which can bring costs down.
Types of Medications for ADHD
A very useful resource that has ADHD medications grouped by type, dosages offered, if they have generic versions available, if they can be put into food or drink, and more is available from the Cohen Children’s Medical Center. This fantastic list of medications can help you and your doctor look at your insurance medication list to pick a medication that is affordable.
Most often the short acting medications are less expensive than the long acting medications. The short acting medications typically last 3-4 hours, whereas the long acting medications last 6-12 hours. Because it is difficult to take medications mid-day for many people, the long acting medications are typically favored.
In general there are stimulants (amphetamines and methylphenidates) and non stimulants (atomoxetine, guanfacine, and clonidine) that are approved to treat ADHD.
Stimulants are controlled substances because they have the potential to be abused and misused. When they are used appropriately for ADHD they have been shown to help prevent drug and alcohol abuse but they require close monitoring by the prescriber.
Which treatment should be first?
This article is about medical treatments, but that does not mean that behavioral therapy isn’t helpful. For preschool aged children, parent training in behavior management is the first treatment preferred. Parent training in behavior management is recommended for at least a part of the treatment regimen for children of all ages with ADHD.
The American Academy of Pediatrics ADHD Guidelines recommend stimulants as first line medical treatment in most instances. One is not preferred over the other. Individuals may respond better to one type of medication over another, but until the medications are tried, it can be difficult to know which will work best.
Family history can help. If a parent or sibling does best on one type of medication, it makes sense to try that medication first.
Pharmacogenetic testing is specifically not recommended in the most recent guidelines. Most insurance companies will not pay for this expensive testing because it has not been shown to be beneficial.
It is important to have close follow up with your prescriber with new medications and routine follow up as long as medications are used. These visits should assess how well they’re working as well as any side effects noted. It can take several medication trials before the right one is found.
If you have side effects, learn to manage them in Tips to Manage ADHD Medication Side Effects.
Please be patient with this process.
I’m a pediatrician who treats many with ADHD, but when my own child was starting treatment it took a few tries before we found the right one. I talk about this and more in A Conversation About ADHD.
Side effects are similar with both types of stimulants, but some people tolerate one medication better than another.
Common side effects include appetite suppression, sleep problems, headaches, stomach aches, and mood changes.
Most of the time either a dose adjustment or change in medication can help alleviate the side effects.
Encouraging eating at times the medication is not active can help with the daytime appetite decrease.
Common long acting amphetamines include Adderall XR, Vyvanse, and Dexedrine spansules. There are others, such as Adzenys XR and Dyanavel, that do not have generic versions available.
Adderall XR is a long acting medication composed of dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate. This is often referred to as mixed amphetamine salts. It lasts about 8-10 hours.
Vyvanse is a prodrug that lasts 10-12 hours. Prodrug means that it is chemically inert until it interacts with an acid in the gastrointestinal tract. It does not have any mood altering effects if it is crushed, injected or snorted, so it does not have the resale value of other stimulants. This is a potential reason that some insurance companies prefer this over more expensive medications.
Dexedrine spansules are made up of dextroamphetamine sulfate. They are less commonly used compared to Adderall XR, but they are available as a generic and name brand. The long acting form lasts about 8 hours.
There are several long acting methylphenidate medicines that have generic versions. These include Concerta, Metadate ER, Focalin XR, Ritalin LA and Metadate CD. (There are others that do not yet have generic versions.)
Metadate CD releases methylphenidate from beads (30% immediate release and 70% extended release) to mimic the effect of 2 doses of immediate-release methylphenidate.
Ritalin LA is also a once-daily agent designed to mimic the effect of the 2 doses of immediate-release methylphenidate. The capsule releases methylphenidate from beads: 50% immediate release and 50% delayed release. It tends to last about 6-8 hours, so it isn’t sufficient for a full school day plus homework for most kids.
The active ingredient in Focalin XR is similar to ritalin, but half of the ritalin molecule is removed, which often helps minimize the side effects. Focalin XR is a 50% immediate-release and 50% delayed-release agent that is similar to using the immediate release Focalin twice a day.
Concerta uses a unique mechanism to release the medication over time. There is an outer covering that immediately starts working, followed by a chamber that slowly and consistently releases medicine over the next several hours. It tends to work for a total of 10-12 hours and avoids the mid-day drop in effectiveness that is common to other forms of long acting medicines.
Generic for Concerta
Unfortunately the laws regarding generic substitutions were written before some of the new technology of medication was invented. The FDA is once again allowing substitutions that use a different delivery system than the original Concerta. I discuss this separately on my other blog if you want more information.
If you’ve noticed a change in your medicine, please keep track of any differences you notice in effectiveness and side effects. If these differences are significant, share this with the FDA. It is easy to file a MedWatch report online – just follow this link and follow the instructions on that site.
It can take a while for enough reports to be filed to trigger an investigation, but it’s the best way to alert them. If they investigate and find that there are sufficient differences, they will remove a generic version. This is what happened in 2014-2016 when the FDA took steps toward removing two generic versions of Concerta.
Please see Gina Perry’s most recent article on generics for Concerta – it’s worth the time if you take Concerta or one of its generics!
Atomoxetine is a non stimulant approved to treat ADHD and has been available as a generic since 2017.
Side effects of atomoxetine include stomach aches, sleepiness, slowed growth (during the first 2 years of treatment), and rarely hepatitis.
Blood Pressure Medicines
Guanfacine and clonidine affect the blood pressure and heart rate. Both are available in short and long acting forms and have generics available.
They can lead to tiredness, dry mouth, dizziness, irritability, headache, and abdominal pain. Most of these side effects are minimized by slowly increasing the dose. Neither should be stopped abruptly due to side effects.
Of course cost is not the only thing to consider when choosing a medication, but if you cannot afford it, you will not be able to continue it. It must be affordable to be a reasonable choice.
There are two things you must check to estimate how much a medication will cost.
One resource to find the cash price is GoodRx. This site allows you to search for any medication and lists how much various pharmacies charge. It also allows you to print out coupons, which may or may not be able to be used with your insurance. They often have a link to less expensive alternatives, which is a very helpful function to estimate if you will be able to afford a medication.
The second thing to always check before starting a long term medication is your insurance formulary and preferred pharmacy.
The insurance formulary is a list of how much different medications will cost if you use your insurance plan. Some will allow you to use coupons with insurance, some won’t.
If you can identify your insurance company’s preferred pharmacy, it might save you money each month. I’ve had personal experience when this didn’t work, so sometimes it pays to visit different pharmacies.
You will also need to know if you can get your medications cheaper as a 90 day prescription. Many insurance companies will not allow a 90 day supply of controlled substances (methylphenidates and amphetamines) but will allow the non-controlled substances (guanfacine, clonidine, and atomoxetine).
Your prescriber will not know which medication is cheapest for you because each individual insurance plan varies – in other words, one Blue Cross Blue Shield plan differs from another Blue Cross Blue Shield plan. One Aetna plan varies from another Aetna plan. The same with United Healthcare and all the other insurance plans. They have many plans that all sound similar.
You can often access this list online by logging into your insurance plan’s website. If you cannot find this list, you will need to speak with someone at your insurance company. When you make this call, be sure to have a list of medications to check easily available. I recommend asking about each of the medicines listed on the Cohen Children’s Medical Center ADHD Medication Guide.
When looking at medications, be sure to look for subtle differences, such as an “ER” or “XR” after the name. These indicate a long acting form of a medication and often cost more than the short acting version of the same active ingredient.
Also check the amount in each pill. For example, methylphenidate ER 30mg is probably a generic for Metadate CD, but methylphenidate ER 36mg is a generic for Concerta (though it doesn’t specify which generic). If you’re not sure what all the medications are, bring the full list with you to your ADHD (or any chronic condition) appointments.
Before you start a new medication, if you have new insurance, or if it is the start of a new year, log into your insurance portal to look up medications before your appointment with your prescriber.
This can help prevent the need for multiple prescriptions for medications that are not affordable. You can work with your prescriber to help find the most cost effective medication that will work for you.
For more on affording medications, please see my other blog’s post, Affording Medications.
If you want to learn more about how medications work for ADHD, see Brain Function 101.
If you need to be convinced that ADHD is a real disorder, see Genetics of ADHD.
CHADD offers Parent to Parent training (a form of parent behavior training).