Update and Release Forms
UPDATE on ADHD Medication
ADHD STIMULANT RX SHORTAGE Update **MUST READ for any patients taking ADHD medications – yes, it’s long!
** IMPORTANT UPDATE and REMINDERS **
When Adderall first was in shortage in Fall of 2022, providers, pharmacists, and patients all hoped it would be a temporary issue. No one would have imagined we would be going into another year of shortages that now encompass many other ADHD medications. The shortage and it’s shifting nature in combination with many insurance plans having LESS medications on formulary and the rising costs of generic and brand medications, added to the high regulation on how these medications are sent and filled, have created a significant barrier and time-cost to prescribing and receiving these medications.
At Mindful Psychiatry, we are committed to continuing to provide evidence-based care for ADHD. This includes continuing to prescribe stimulant medications as a first-line treatment for ADHD. As your providers, we value your time and our time spent with you in appointments. This time should be spent focusing on your care, discussing your symptoms, reviewing treatment efficacy, and collaboratively discussing a personalized treatment plan. We are finding that we are spending an increasing percentage of our time together... and significant time beyond our scheduled appointments... in trying to manage what your insurance covers, reviewing the shortage, discussing contingency plans, etc. This is not sustainable.
We face the reality, alongside our patients, that when we send a prescription or discuss options, it may not be available at the pharmacy immediately – or for a number of weeks. As this has become a chronic and continuing situation, we find it necessary to remind patients of our original operating policies and procedures, as well as share expectations for preparing for your appointment to help ease some of the current scramble.
Key Points
1. The shortage is still here and likely will continue. We are facing the very real situation of this continued shortage and challenges. NEW FEDERAL laws currently allow the transfer of schedule II stimulant medication at one pharmacy to another from a licensed pharmacist to a licensed pharmacist, HOWEVER the state of Florida has not yet adopted this. We are hopeful and will keep you apprised if this changes.
2. Reminder of Policies and Procedures: Temporarily we responded to the initial acute phase of the shortage by making exceptions to our Policies and Procedures. This is no longer feasible. As the shortage has become an ongoing chronic situation, we need to return to the standard and best practices outlined within your original signed Policies and Procedures.
These include:
o Prescriptions for controlled stimulant ADHD medications will ONLY be sent at your appointment, with very few and rare exceptions.
o Medication changes, dose changes, and formulation changes will ONLY happen at an appointment. This includes situations arising due to the shortage (i.e. your pharmacy is out of stock of the medication we agreed on in your appt, your insurance won’t cover it, etc.) – in the event these situations occur, you will need to wait for an appt to discuss a potential alternative.
o Controlled stimulant ADHD medications will ONLY be sent on regular Mindful Psychiatry business days (Tuesday, Wednesday, & Thursday), unless you have an appointment with your provider on a Monday or Friday (it would be sent at the conclusion of that appt).
o The Urgent button should ONLY be used for clinically urgent situations. It should NOT be used for refill requests, transferring prescriptions, situations where the pharmacy doesn’t have the ADHD medication, etc.
o Expanded information on this is detailed below. We advise you read this in its entirety.
3. We need your partnership so we can return to spending your appointment time with you on your treatment. After almost two years, the ADHD medication shortage is a chronic situation, not an acute or emergent situation. We urge you to follow the steps below to help minimize delays in getting your medication.
A. WE NEED YOUR FORMULARY list of ADHD medications ASAP!!!! Given the rising costs of ADHD medications (both generic and BRAND), and the changing formularies of insurance companies in 2024, we need this information in advance of your appt in order to make any changes to your ADHD medications. AS ADHD treatment is becoming increasingly complicated by the shortage, this is one simple step that can help you and your provider choose a cost-effective medication. If you do not have insurance, you may look up medication costs on GoodRx.
• ALL Patients who want or need to make a change in their ADHD Medications need to provide our office with the formulary IN ADVANCE of the appointment. As these medications will ONLY be sent at an appointment, having this available BEFORE your appointment will allow your provider and you to spend your appointment discussing available options and choose a medication that will be covered.
• Even if you have always taken the same medication, it is better to send the formulary to us now – just in case! Failure to send this to us will lead to your provider needing to delay making any changes to your medications if a situation arises where you need to change.
• If we do not have your FORMULARY information at the time of your APPT, we will not be able to change your ADHD medication from what was last prescribed – EVEN IF YOUR CURRENT MEDICATION IS CURRENTLY UNAVAILABLE (Unless you are paying for your medication out of pocket without the assistance of insurance)
• PLEASE send this to us ASAP. We really do not want to tell you NO in the appt, but will do so without this information. Some of these generics are running $300+/month with the brands being over $700 - our hands are tied without this information. Even if we check on our EHR and discuss many treatment options, without having formulary information AT YOUR APPOINTMENT, we may spend time talking about a medication, sending it, completing the prior authorization, only to find out a week or more later that the chosen medication was not on formulary. This delays your care and causes a scramble and stress. If we do not have your Formulary AT YOUR APPOINTMENT, it may lead to you having to delay making a change and scheduling another appointment sooner.
• Should you be interested in a newer medication, please check your insurance prescription cost. Most insurances have a page on your account that lets you check the predicted cost. Most Brand medications have copay cards that detail how they help lower costs. Providers will not be able to provide you with specific pricing information during your appt. Checking the price for the desired medication through your specific insurance plan in advance allows you to know the cost of the medication you are interested in starting to see if it a reasonable/sustainable cost. Providers do not have access to each individual plan and the intricate differences in insurance plans and medication tiering costs. But many insurance plans have an easy site where you can type in the medication and lookup the expected cost.
B. Come prepared to your appointment with:
• Your formulary for your insurance (you can send that to us now and we will load it into your chart and keep it for future appointments). – Yes – we’ve said this five different ways. WE REALLY NEED IT!!!!
• What pharmacy you want to use – the controlled Schedule II ADHD medication will only be sent to ONE pharmacy. It will not be transferred due to shortages or backorder.
• All pharmacies nationwide are experiencing shortages and we advise calling your pharmacy the day before or the day of your appointment. As it is currently – patients are needing to call pharmacies, but it is being done AFTER their appointment – and this is leading to a very stressful scramble AND double work, along with sending controlled medications outside of an appointment, which does not align with our policies and procedures that are based on best practices for Schedule II controlled medications. This will no longer be an option.
• If you are only seen every two to three months, make sure to contact your pharmacy in advance of each time you will be picking up your medication. We understand this can lead to frustration – we’re all in this together. For us to continue providing care and treatment for ADHD, we need your active partnership and participation.
C. ALL ADHD MEDICATIONS are safe to discontinue abruptly and without taper. There may be fatigue and increased symptoms of ADHD if the medications are discontinued abruptly, but there are no life threatening sequalae.
• If you know you will be running out, lowering your dose (if possible), and reducing doses over a couple of days can help.
• Should you be in a situation where you have significant side effects or adverse effects with a new ADHD medication or dosage, please discontinue it immediately. Make sure you let us know on Spruce that you have stopped the ADHD medication. Alternate medications or prescriptions for your previously taken medication can be provided at your next appointment.
D. ALL ADHD MEDICATION can be taken intermittently. These medications can be life changing and provide significant benefit. But they do not need to be taken daily. Running out of the ADHD medications is not a reason to use the URGENT button and it is certainly not a life-threatening event.
• It is your responsibility as a partner in your treatment for ADHD to know and EXPECT the real possibility there will be delays in getting your medication and to prepare for that accordingly (see below).
• We are actively encouraging patients to take days off, so that they can weather pharmacy delays and still have some remaining to take their medication on their work days.
• Higher doses can be harder to take intermittently and can have more of a negative impact if you do run out. If you do find it too difficult to completely skip some days, consider lowering your dosage on days where less could be enough. This lowering could lead to a “backup supply” to combat any delays. Consider discussing this with your provider at your next appt.
4. What we’re planning to implement:
• We will continue monitoring if there are any changes in laws and rules in the State of Florida and keep you apprised.
• We will be reviewing research and literature and anecdotal information and sharing some posts on our Facebook page and website to provide some information on ways to supplement your medications for ADHD as well as complementary and alternate treatment options. We may even be testing some of these recommendations and posting anecdotal reviews!
• Your providers are currently working to create a block of time for SAME WEEK abbreviated appointments that will be reserved for our patients impacted by the ADHD stimulant shortage.
▪ Prior to this appointment, the patient would provide the office with their formulary (if they have not done so yet) and will come prepared with which pharmacy they will be using. (LOOK! We’re talking about the FORMULARY again!)
▪ This would be an abbreviated appointment with a sole focus on your ADHD medication and intended to be able to quickly meet and review the new ADHD medication or ADHD medication change. This time block can also be used when patients do not want to wait for their pharmacy to be in stock and are wanting the medication transferred to a different pharmacy before their next appointment – or for any FORMULARY stragglers! ☺
Expanded Information and Details
1: CHANGES in FEDERAL and STATE LAWS in 2023
Efforts have been made at the Federal and State level to try to help with these shortages. Most patients and pharmacies are NOT AWARE of these changes at both the Federal and State level. Probably one of the worst things currently is that even if a patient is able to find a second pharmacy that has their medication --- even if the patient is contacting their provider on normal business days, by the time the patient message is seen, the provider is able to take the necessary steps to properly send the prescription, and the pharmacy is able to process the prescription ---- that may no longer be there and it’s back to the square 1 after a lot of time and stress for all three parties involved (patients, pharmacies, and providers).
NEW FEDERAL FINAL RULE from the DEA - effective August 28, 2023 – patients can ask their pharmacy to transfer their original prescription of a Schedule II-V medication (which includes stimulant ADHD medication) at the patient’s request. It can be transferred WITHOUT a new prescription being sent from your provider’s office. This means, if you find somewhere that has your medication – you can at that moment request it be transferred directly.
FEDERAL Final Rule
- Document Citation: 88 FR 48365-48380
Agency/Docket #: Docket No. DEA637
“Under the final rule, a prescription can only be transferred once between pharmacies, and only if allowed under existing state or other applicable law. The prescription must remain in its electronic form; may not be altered in any way; and the transfer must be communicated directly between two licensed pharmacists. It’s important to note, any authorized refills transfer with the original prescription, which means the entire prescription will be filled at the same pharmacy."
https://www.dea.gov/stories/2023/2023-09/2023-09-01/revised-regulation-allows-dearegistered-pharmacies-transfer https://www.federalregister.gov/documents/2023/07/27/2023-15847/transfer-of-electronicprescriptions-for-schedules-ii-v-controlled-substances-between-pharmacies-for
FLORIDA STATE LAW
Florida does not currently match Federal law for transferring Schedule II stimulant medications. But we are keeping you posted as we hope this may come soon. They did however pass an update to 465.026
“The transfer of a prescription for medicinal drugs listed in Schedules III, IV, and V appearing in chapter 893 for the purpose of refill dispensing is permissible, subject to the requirements of this section and federal law. Compliance with federal law shall be deemed compliance with the requirements of this section.”
http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400- 0499/0465/Sections/0465.026.html
2: Reminder of Policies and Procedures
We find it necessary to provide this reminder of our commitments to your care at Mindful Psychiatry, as well as your responsibilities as a partner in your care. While we have made exceptions when this was an acute situation, it is important that we return and continue to follow our current policies and procedures with diligence. So that this is not a shock, we are providing it in detail below.
A. Your appointment time is reserved with your provider to discuss medication options, dosages, and send your prescriptions.
1. Medication changes to a new/different medication for ADHD will ONLY happen AT AN APPOINTMENT
2. Medication changes in dose (i.e. changing from original prescription of 15 mg 1 tab daily vs. 10 mg 1 and ½ tablets) or formulation (i.e. changing from regular immediate release to extended release) will ONLY happen AT AN APPOINTMENT
3. Prescriptions for controlled medications will ONLY be sent AT AN APPOINTMENT.
4. MISSED APPOINTMENTS. NO SHOWS, and Late Checkins - If you miss your appointment, oversleep, or reschedule an appointment past when you will run out, these choices may lead to an interruption in your provider sending your controlled stimulant medication, since these meds will ONLY be sent AT AN APPOINTMENT.
5. The controlled stimulant medications for ADHD are heavily regulated and monitored medications. New medications are only started at an appointment so your provider has adequate time to safely and effectively discuss these. THIS INCLUDES dose changes and changes in formulation or changes between medications you’ve taken in the past. IF you were started on a new stimulant medication and fail to attend your follow up visit, the new medication may not be refilled until you attend a follow up appt for adequate review.
6. There are a limited number of exceptions to this i.e.
o You have called your pharmacy and after talking to a person in the pharmacy, they are unable to find the prescription your provider sent – in which case our team may assist them in finding it or we may resend it during normal business hours Tuesday to Thursday. It is your responsibility to check on your prescriptions in advance and to allow a 1-2 business day processing time for these requests.
o Your provider has specifically discussed it with you at your appointment and they have a clinical reason for doing so.
o Your provider has an unplanned change in their availability and there is not an available follow-up with your provider or a covering provider before you will run out of medication.
7. Controlled medications WILL NOT BE SENT during Friday, Saturday, Sunday, or Mondays --- unless you have an appointment that day with your provider.
o Sending controlled medications represents a significant amount of time. Controlled medications are not allowed to be called in. When sent, the provider must be logged into multiple electronic devices and perform a number of necessary steps to be compliant with federal and state laws and regulations when sending them --- even if it is “simply” transferring it to another pharmacy or “simply changing the dose”. Most providers are physically not able to send your prescriptions for controlled medication when they are not “in the office”. Sending the same prescription to multiple different pharmacies is not as simple as “just clicking a button”. This is simply not feasible when your providers have 250 or more patients. Thank you for understanding.
B. OFFICE HOURS and USE of the URGENT BUTTON
Mindful Psychiatry’s regular office hours are Tuesday to Thursday, 9 am to 5 pm. Outside of these hours, you may send or leave a message to be addressed when the staff and provider return the next scheduled day. At Mindful Psychiatry, we pride ourselves in providing an improved communication platform with secure messaging, and we ask for your consideration in using that communication. We have enabled an Urgent button for you to press on your secure messaging or as an existing patient when you text our office number.
If you mark your message as urgent, and it is a clinically urgent matter, we remind you that outside of normal office hours, your provider will often be unavailable to respond for up to 48 hours if they are out of town, unable to be in a secluded and confidential environment, out of cell phone service, etc. Should you be unable to wait for the provider to respond regarding an urgent question or if your symptoms worsen or become severe or an emergency situation; please go to the nearest emergency room or call 911. You may use Coastal Psychiatric Urgent care for any urgent needs that cannot wait for your providers response (note: they do not prescribe any controlled medications).
THE URGENT BUTTON SHOULD ONLY BE USED FOR CLINICALLY URGENT SITUATIONS involving a change in symptoms or side effects that cannot wait for the next business day. When you mark URGENT, this sends your provider a text to their cell phone.
1. Should the URGENT button be used for non-urgent questions, medication refills, or pharmacy change requests, this request will be reviewed and responded to on the provider’s next business day, per our policies and procedures.
2. After-hours messages and messages in between your appointments are not a substitution for an appointment. Non-urgent questions may be directed to be addressed at your scheduled appointment, as this is the time set aside to discuss your care.
3: Information on insurance, formulary, cost, and patient preparation before your appointment
A. Patient Formulary:
With the rising costs of ADHD medications, large number of new and old medication options for ADHD, and changes in health care formularies ---- our providers NEED this information BY THE START OF YOUR APPOINTEMNT so that we can effectively discuss clinically which is the best option of the medications that are covered by your insurance. Currently, it is a large time cost where you sit and watch us trying to figure out which medications are formulary by entering different medications into our EHR and hoping it’s accurate, or we send the prescription, do a prior auth, only to find out after a week that it is not covered or is too expensive.
All insurances have to have a posted formulary list that will include what medications are in formulary, and which medications are not. The formulary is the list that says what medications are covered by your specific plan and it has codes that help us know if it's likely to be covered. They are usually broken into sections based on the type of medication or condition (ADHD, or stimulant). This can usually be found online as a pdf, or a searchable database, or as a print copy. IF you have difficulty finding your formulary, you may email or call your insurance plan.
This information can be provided to us through a number of ways. Choose what is easier:
- You can use the + symbol on Spruce to attach a pdf or picture
- Email (as long as there is no confidential information): office@mindfulpsychiatry.sprucecare.com
- Office Fax: (321) 616-8126
B. Patient Pharmacy Selection:
This needs to happen BEFORE your appointment. Given the shifting nature of the shortage, we know stock can change quickly. There is a nationwide shortage and most patients are experiencing a delay of 3 to 8 days, or longer. Contacting your pharmacy the day of your appointment or the day before your appointment may help you come prepared with which pharmacy and which dosages/formulations of your medication may be in stock.
1. Reviewed above, moving forward, medication formulation changes and dose changes will ONLY happen at an appointment, unless there are extenuating circumstances.
2. Providers will no longer be transferring medications between pharmacies, unless there is an extenuating circumstance (you’ve permanently moved addresses, your insurance has changed their partnered pharmacy, etc.).
3. In these past months, we have noticed that switching pharmacies often causes the same effect and often may put the patient back to the beginning of the line. There is an inherent delay between when you find out what pharmacy has your ADHD medication and when we are able to send it. Some pharmacies are not accepting new patient prescriptions for stimulants at this time due to the shortages.
4. We do not have access to view pharmacy stock. The only person who can tell you if your pharmacy has a medication in stock is your pharmacy. We are aware some pharmacies won’t share that information – as they sometimes won’t even share it with us. You may try creatively asking: “If I am seeing my provider tomorrow, should I ask them to send you the Adderall 10 mg or Adderall XR 10 mg?”
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