Insurance Denied Our Son’s ADHD Medication — How Prior Authorization and Appeals Got Us to Yes

My son, who I'll call Joseph, was diagnosed with ADHD and anxiety about five years ago when he was in first grade. Like many families navigating ADHD treatment, our journey wasn't as simple as finding the right medication upon the first prescription. We spent years trying different options while working closely with his psychiatrist, Dr. Annette Reynolds, MD, at LifeStance Health. Some medications helped. Others didn't.

Adderall made Joseph react aggressively and wasn't a good fit.

Guanfacine, a non-stimulant medication sometimes used for ADHD, left him too lethargic to function normally.

Concerta (a methylphenidate) worked well for a while. Like many stimulant medications that contain methylphenidate, it helped improve focus and attention. But eventually, Joseph reached the highest dosage that was appropriate for him, and because his body had become accustomed to the medication, it was no longer reducing his ADHD symptoms.

Next, we tried Focalin. It helped during the school day. By the time class started, the medication had taken effect, and Joseph could focus more successfully on his academic assignments. But our mornings remained chaotic. Despite posting minute-by-minute routines to create a visual schedule, setting timers, or creating a token reward system to reinforce new habits, it was a daily battle.

“Put on your socks please.” (repeating over and over)

“Your medicine has been right in front of you all morning … please take it.” (repeating over and over)

Simple tasks often required multiple reminders because he didn’t have the medication support. An already rushed and difficult time in the day became utterly exhausting.

Then, with Dr. Reynolds’ recommendation, we found Jornay PM.

Unlike other ADHD medications, Jornay PM is taken at night and is designed to begin working the following morning. As a methylphenidate-based medication, it treats ADHD symptoms, but its delayed-release into the body makes it better suited for some individuals who experience ADHD symptoms before traditional morning medications take effect.

For Joseph, the difference was remarkable. He woke up ready to start his day. He could get dressed. He ate breakfast. He brushed his teeth. He stayed on task with minimal prompts.

Instead of beginning every morning with frustration and constant corrections, our family experienced something we hadn't felt in a long time:

Relief.

Most importantly, Joseph started each school day with a chance to feel successful instead of defeated. Similarly, as a parent, I felt more at peace because interactions with my son were pleasant rather than draining.

The summer before Joseph’s sixth grade school year, we unexpectedly had to switch insurance plans. Since our former insurance covered Jornay PM and it’s currently the only ADHD medication taken at night (so there is no alternative), it didn’t even cross my mind that an insurance change would affect Joseph’s medications.

However, the new insurance company denied coverage for Jornay PM. Their explanation was that Joseph needed to try other medications first.
I was stunned.

Over the previous five years, Joseph had already tried multiple medications. It's not like we were seeking an experimental treatment. We were trying to continue the medication that was already helping him succeed.

Without insurance coverage, Jornay would cost us approximately $500 per month. That's not a sustainable expense for most families, including ours. Suddenly, we faced a question many parents know all too well:

What do you do when the medication your child needs is the medication your insurance company won't cover?

Thankfully, Dr. Reynolds stepped in and explained that we needed to pursue something called a prior authorization, often referred to as a PA.

A prior authorization is essentially a request from your healthcare provider asking an insurance company to cover a medication, treatment, or service that requires additional review before approval. The provider must explain why the medication is medically necessary and why other options may not be appropriate. In a study published in 2024 by Health Affairs Scholar, participating psychiatric providers reported that approximately 75% of PA requests are ultimately approved, including those approved after appeal.

Dr. Reynolds submitted the first PA. She documented Joseph's history and explained the medications he had already tried, but the insurance company denied the PA and covering Jornay PM.

Without hesitation, Dr. Reynolds tried again.

The second prior authorization emphasized something critical: Jornay PM is the only ADHD medication (currently) with its unique nighttime dosing and delayed-release design that provides symptom control immediately upon waking. For Joseph, treating the morning hours was the entire reason the medication was successful.

Given there is currently no other ADHD medication that takes effect in the morning after administering at night, I was confident our insurance would see their error and support us. Still, the insurance company denied it a second time.

I felt like I had been punched in the gut and could barely breathe.

Dr. Reynolds leaned on her years of experience in working with insurance companies and initiated an appeal. She also requested and completed a peer-to-peer review.

A peer-to-peer review allows the prescribing physician to speak directly with a doctor working on behalf of the insurance company. Rather than relying solely on paperwork, they can discuss the patient's situation and clinical needs in detail. I had no idea this was an option, but Dr. Reynolds explained how she’s completed these many times in the past.

During the peer-to-peer conversation, Dr. Reynolds advocated for Joseph.

She explained that:

• Joseph had already tried several medications the insurance company preferred.
• Some caused significant side effects.
• Others were no longer effective.
• The only remaining medication on the insurance's preferred list was one she had seen perform poorly with similar patients and did not believe was the right recommendation for Joseph.
• Jornay PM was already working well.
• Most importantly, forcing a medication change immediately before the start of a new school year was not in Joseph's best interest.

The insurance company's doctor listened and noted that they hadn’t seen Joseph’s complete medication history (that was originally sent), which made a difference in their decision making. We don’t know where or how that critical information was lost in communication.

Above all, Dr. Reynolds didn't give up after the first denial.

Or the second.

She kept fighting.

This time, the insurance company approved the coverage. I could finally breathe easily.

Dr. Reynold’s persistence in exhausting all avenues until the insurance company approved my son’s coverage of Jornay PM was so critical.

When I tell this story, people often focus on the outcome.

Yes, we were grateful the medication was approved. Yes, we were relieved we wouldn't have to pay hundreds of dollars every month.

But what stays with me most is something else.

For weeks, Dr. Reynolds continued advocating for Joseph when it would have been easier to accept the denials and prescribe a less effective, but insurance-covered, ADHD medication.

She knew his history and what was at stake: success isn't just about what happens during Joseph’s school hours, but about his entire day, especially from the moment he wakes up. That every waking hour affects his confidence, relationships, and self-esteem, impacting whether he spends more of his day expecting to fail or relishing in success.

She knew Joseph’s Jornay PM prescription was the right treatment for him and made sure that our insurance saw it that way too, no matter how many times she had to prove it.

If you're facing a similar situation and insurance has rejected your medication coverage, don't assume a denial is the final answer.

Ask your provider whether:

• A prior authorization can be submitted.
• Additional documentation may support medical necessity.
• An appeal is appropriate.
• A peer-to-peer review is available.

In some cases, insurance denials occur because of prior authorization requirements, coverage policies, missing documentation, or other administrative issues that may be resolved through additional review. Specifically, 2024 federal transparency data for Affordable Care Act (ACA) Marketplace plans showed that only 5% of in-network claim denials were attributed to lack of medical necessity, while 25% were attributed to administrative reasons and another 36% to reasons the insurer didn't specify. Partner with an experienced psychiatrist who can often help navigate these hurdles.

Mental health treatment is rarely a straight line. Finding the right medication can take time and navigating insurance may be frustrating. There might even be moments when it feels like the system is working against you.

I've been there. But our family's experience also reminded me of something important:

There are providers who will keep advocating when the process gets difficult. There are psychiatrists who will make the extra phone call, submit another appeal, and continue fighting for what's medically right.

And that above-and-beyond support is what you deserve too.

Today, Joseph is thriving. He started middle school with the medication that works for him, supported by a psychiatrist who refused to give up. As parents, it's so refreshing and empowering to know we have the right team around him and our family.

Dr. Reynolds, we are forever grateful.

Medications are prescribed only when clinically appropriate. Not every medication is suitable for every patient, and medications should only be taken as prescribed by a qualified healthcare professional. Insurance coverage requirements, medication availability, and prior authorization processes vary by health plan and geographic location. Individuals should confirm treatment availability and insurance coverage with their provider and insurance carrier.