Finding the Best ADHD Medication You Can Afford

Finding the best medication for ADHD management includes finding one that is affordable. Is a generic version the answer?

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.

Not anymore.

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.

Stimulants

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.

Amphetamines

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.

Methylphenidates

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.

For more:

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!

Authorized Generic Concerta – Yet another update

Non-Stimulants

Atomoxetine

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.

Checking Prices

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.

Online resource

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.

Here’s a screenshot of checking GoodRx. The coupon for Quillivant XR is still pretty expensive, but sometimes it is much cheaper than paying using insurance.
In this example, you can see that the least expensive place to shop without insurance and with the GoodRx coupon is CVS, but it doesn't tell you what you would pay if you use your insurance. Many people can get this for under $42 if they just use their insurance. #formulary @adhdkcteen
In this example, you can see that the least expensive place to shop without insurance and with the GoodRx coupon is CVS, but it doesn’t tell you what you would pay if you use your insurance. Many people can get this for under $42 if they just use their insurance.

Insurance Details

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.

I took this screenshot as an example of the various medication lists after searching "BCBS medication." The best way to find your list is to log into your insurance portal and look for it. #formulary @adhdkcteen
I took this screenshot as an example of the various medication lists after searching “BCBS medication.” The best way to find your list is to log into your insurance portal and look for it.

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.

Best Bet

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

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).

Finding the best medication for ADHD management includes finding one that is affordable. Is a generic version the answer?

Psychosis From Adderall?

If you worry about headlines reporting new research findings, look at the facts before making a decision. Headlines are written to get your attention. They never tell the whole story and even statistics can be used inappropriately.

Headlines are designed to grab your attention. Recent headlines about Adderall and other ADHD medications are scary. This is another example of media misinterpreting a study with the headline. I’ve written before about Adderall being misrepresented by headlines.

When headlines say something shocking, don't just believe them. Read critically. The study that shows adderall decreases brain function doesn't apply to those with ADHD.
Stimulants decrease brain function? Say what?

In this post I will generally refer to stimulants by their common names. Adderall is in the amphetamine family and as used here could include other named medications in that family. Ritalin is in the methylphenidate family and as used here includes other medications in its family.

New: Psychosis with Methylphenidate or Amphetamine in Patients with ADHD

That sounds like a typical headline. It’s eye-catching, right? It won’t be something you forget if you take Adderall or are considering starting it.

If these medicines have been working well for you and you aren’t hearing or seeing things, you don’t need to stop them.

How can I say that? Am I not worried about someone becoming psychotic?

We always need to look at studies critically. The title of an article, or even the summary, can be misleading. Attempt to read the study itself, but if you are unable to, find a summary by an expert in the field.

Limitations in the study

This study actually fares well in many of the above things to consider when evaluating a study. It’s a respected journal and there’s a large sample size, but it’s not a double blind controlled study. It’s a review of insurance codes. This can be fraught with many problems.

Study design

The study was a review of codes from national insurance claim data. It included teens and young adults who were starting these medicines for the first time. They reviewed codes for diagnoses as well as prescriptions. They did not have any direct study of the patients. Anyone who was doing well on these medications already was excluded.

Unable to accurately assess disqualifiers

Anyone who had filled a prescription for a stimulant in the year prior to the study was disqualified. That means the many, many people who use stimulants with great benefit for years were not included. There is no comparison to total number of prescriptions for this.

We know that many people will self medicate with someone else’s medicine. There was no way to assess if they used someone else’s prescription medication, so there could be misrepresentation of new medication starts in the study population. This means even one of their qualifying conditions cannot be verified.

Inability to assess if patients accurately took medicine

We all know that people will fill prescriptions that they don’t take as directed.

There is no way to tell from this study design if the patients took their medicine regularly, or even at all.

Adderall has a larger street value than ritalin, so if more of the patients who were prescribed adderall diverted their medicine to someone else, they were still included in the psychosis number. This could sway the numbers making adderall look more problematic than ritalin because they weren’t being medicated. Said in another way: if people are more likely to take their medicine, they’re less likely to have psychosis.

This is just a thought. I have no way of knowing this information based on the study design. I include it because this is the way we must evaluate study results. We need to consider the results and other possibilities and explanations critically.

What does double the risk really mean?

The age range studied is one at which schizophrenia and other psychoses tend to develop.

They compared psychosis rates to people treated with methylphenidates versus amphetamines and found the risk was double in those starting amphetamines. Double sounds huge, but it was still very small numbers.

No comparison

One big problem is that there was not a comparison to a baseline development of psychosis in people of the same age not on medication.

We would expect a small number of study participants to develop psychosis, whether they start the medicine or not. They did not attempt to compare this with their study population.

Incidence estimates of new psychosis in the general population in one study showed 126 per 100,000 among those aged 15 to 29. This means that about 0.12% of people are expected to develop psychosis in this age group each year.

Risk of psychosis in those with ADHD

We also know that people with ADHD struggle more with mental health.

Their overall risk of psychosis may be higher, but since they didn’t compare the same age range of people (with and without ADHD) who did not start any new medications during the same time frame, we do not know that baseline.

Study results

The recently announced study about new psychosis related to new amphetamine or methylphenidate shows 343 episodes of psychosis among the 221,846 study participants between 13 and 25 years of age. The group of people starting methylphenidate had a 0.10% risk and those on amphetamines had 0.21%.

The age groups in the studies are slightly different. We know that risk increases with age, so it should be further studied if the age range contributed to this difference.

Closer follow up matters

It is also possible that people who are starting a new medicine are more likely to be identified early in their psychosis.

Many adolescents and young adults rarely see physicians or other medical providers since they’re generally healthy. If they aren’t seeing someone who could identify psychosis, they would not get a diagnosis.

People who see someone who is prescribing stimulant medications are hopefully being assessed for mental health in general. It is expected that they are more likely to have problems identified.

This wouldn’t explain the difference between medicated groups, but could raise the incidence overall identified.

TL;DR

This study doesn’t convince me that the risk of psychosis is enough to avoid using it for the management of ADHD. Both amphetamines and methylphenidates have been used successfully in many people over the years.

If you have been treated successfully with any treatment and aren’t having significant side effects you should continue the treatment. Not treating has risks too.

For more reading

Methylphenidate and the risk of psychotic disorders and hallucinations in children and adolescents in a large health system Transl Psychiatry. 2016 Nov; 6(11): e956.

Tips to manage ADHD medication side effects

Are you struggling to control side effects from your ADHD treatment? Learn some tips to help manage them effectively so you can thrive with ADHD!

With everything we do, we must weigh risks and benefits. Many people with ADHD need help managing their symptoms, and that often includes medications. Unfortunately this treatment can lead to side effects. If we can manage the ADHD medication side effects, the risk to benefit ratio tips toward the benefit side.

1. Appetite suppression

A decreased appetite is common when stimulants, such as methylphenidates or amphetamines, are used. I have seen kids who gain weight better on their medicine because they can actually sit long enough to finish lunch, but most will lose a few pounds when they first start their medication. After the initial drop, most can maintain a healthy weight with some simple adjustments.

Make the most of non-medicine times

I often say that kids on stimulants don’t have eating disorders, but they have disordered eating. They eat at unconventional times.

Before meds kick in

Start your day with a healthy breakfast that includes protein, whole grains and fats. The typical American diet of cereal for breakfast is mostly carbs, which gives quick – but non-sustaining – energy.

Protein, fiber and healthy fats can provide longer-lasting energy.

Don’t limit yourself to “breakfast” foods. If a sandwich or leftovers sound good to you, eat that for breakfast.

As meds wear off

Before hanger sets in, grab a healthy snack at the time you start to feel hungry in the afternoon or evening.

If your parents try to make you wait for dinner, talk to them about how your hunger affects your mood and behavior.

Eating a healthy snack (or call it an appetizer) can help keep those under control. You should still be able to eat dinner, but if it affects your appetite, warm up last night’s dinner as your appetizer each day. You’ll still eat what the family eats, but it will be timed differently. Still sit with your family for the conversation if your hunger doesn’t coincide with the family dinner. Family meals are important!

After school if you’re hungry, grab a mini-meal. Heat up leftovers, make a sandwich, or grab a plant and protein pair.

Healthy pairings:

  • apple slices, grapes, or berries with cheese
  • bell peppers with cream cheese
  • berries and yogurt
  • cucumbers, carrots, bell peppers or snap peas with hummus
  • apple, banana or celery with peanut butter
  • smoothie made with fruits, vegetables, and yogurt
  • broccoli, carrots, cauliflower, snap peas or celery with a yogurt dip
Pair a plant and a protein for healthy eating! www.adhdkcteen.com

If you’re hungry after dinner, again grab a mini-meal type snack, not junk food.

Don’t waste empty calories

If you’re able to eat, pick the healthiest part of the meal first. Don’t start with the side dish or roll. Eat plants and proteins. Plants are fruits and vegetables, and most of us fail to get the recommended amount of these daily.

2. Moodiness

People with ADHD tend to be very sensitive and emotional in general, but medications can increase moodiness at times. Look for patterns about when the moodiness is the worst to help identify why it happens.

Some people get more irritable when their medicine is working, others as it wears off. This can be due to a medicine that’s not the best fit or at the wrong dose. Be sure to talk to your prescriber about how your medicine is affecting your mood.

Rebound

Many people experience a rebound of symptoms as the dose wears off. If this happens, some people can use non-medication changes, others require a medication adjustment.

If you can be alone during this time frame, that may be all you need.

Listen to music. Exercise. Read. Whatever helps you adjust.

If this isn’t sufficient, discuss adjusting the dose or adding a short acting dose in the afternoon with your prescriber.

When these medication adjustments aren’t sufficient, adding a non-stimulant medicine can help buffer the rebound. Again, talk to your prescriber.

Anxiety

Sometimes stimulants can can trigger an underlying anxiety.

Anxiety can look like anger or increase irritability.

It can lead to headaches, stomach aches and other physical symptoms.

Anxiety is a common cause of insomnia. Lack of sleep makes anxiety worse. It’s a hard cycle to break sometimes. Talk to your prescriber if you’re experiencing this.

When anxiety distracts, it can look like poor focus, which can be misintrepreted as too little stimulant. Increasing the stimulant makes it worse.

Anxiety often leads to avoidance, negativity, over planning and trouble with patience.

Help for anxiety

Therapy is the first line treatment for anxiety, but if it is caused by medication, adjusting the medication can help.

Sometimes adding another medication to help with the anxiety may be needed.

It is very important that you talk to your prescriber about any anxiety you have, whether it’s medication related or not. No one should suffer in silence.

Other causes of moodiness

Moodiness can be related to chronic sleep deprivation or hunger – see the related sections of this post to help manage those issues.

3. Sleep problems

Sleep problems are common in teens, especially those with ADHD. Sleep deprivation can lead to many problems, so it’s important to address them.

There are many things we can do to get more sleep. These are covered in How can I get better sleep?

If you think your medicine keeps you up, talk to your prescriber about changes that could help.

4. Stomachaches and headaches

If stomachaches or headaches seem to happen due to the medication, taking the medicine with food can help.

These symptoms sometimes only happen at the start of a new medication, when the dose is increased, or when resuming after being off of it for awhile. If this is the case, you should notice these side effects go away after consistent use.

When the stomachaches or headaches are persistent and not tolerable, talk to your prescriber to discuss changing medicine or changing the dose.

5. Tics

Repeated movements or sounds are known as tics.

Tic disorders are common in kids with ADHD:

  • About 20% of kids with ADHD have chronic tics.
  • Around half of all children with chronic tics have ADHD.

Tics can come and go. They often change over time, so an eye blink can go away and be replaced by a nose twitch or shoulder shrug.

Because of this natural cycle it can be difficult to decide if they’re on their normal cycle or worse due to medication.

While it was once common to believe that stimulants cause tics, there is evidence to the contrary.

Some people will even notice that their tics are less common when they’re on medication for ADHD, especially with guanfacine or clonidine.

If you note that tics increase with the start of a new medicine or an increase in dose, evaluate how these tics affect you. If they are minor, such as an eye blink, it is okay to ride it out. The tic will most likely continue to come and go and it’s not causing distress. If it causes you distress, talk to your presciber about behavioral therapy or a medication change.

6. Psychosis

Recent headlines have put psychosis and stimulants in the news.

Psychosis from Adderall is all over the news. Headlines are scary. Learn what you need to know. @adhdkcteen

In short, if you’re doing well on a stimulant, either amphetamines or methylphenidates, there’s no need to worry.

The study being reported is about new starts on these medications.

As is often the case, headlines are overestimating the risk. They are designed to make you want to read the article.

I am writing a whole post on this, so tune in next time… if you don’t want to miss it, sign up in the pop up or the right sidebar so you’ll get each new post in your in box. I promise to never use your email for any other purpose!

Meds don’t last long enough?

If your medicine doesn’t last long enough for your schedule, check out My Medicine Stops Working Too Soon!

If you still feel like you’re struggling…

Our next meeting will be all about growing up and thriving with ADHD.

Paula Smith-Culp from ADDvantagekc and Jonathan Kindler, a local therapist at Serenity Life Resource Center and KC Wolf alternate, will share their journeys from childhood to adulthood.

This presentation will be of interest for all ages living with ADHD. It will include experiential activities, and guidelines for using ADHD strengths in order to follow your passion from childhood to the workplace!

This will be a combined group of the parents and students. We appreciate your RSVP so we can plan seating, but if you decide to come at the last minute, you’re welcome to show up! All meetings are free and open to the public. RSVP here