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Abilify and health insurance
PrincessLeia56022 posted:
I have been taking Abilify (5mg) for a few years in addition to my Lexapro. This past weekend when I went to the pharmacy to get a refill of the Abilify, I was told that insurance wasn't going to cover it any more. I have insurance through Highmark. I talked to my doctor about it and she gave me some samples and is going to write an appeal for me and explain that I need this medication.

Does anyone know anything about this or has had a similar experience?
susiemargaret responded:
hello, leia --

i'm so sorry i didn't see your post until now.

unfortunately for patients, ins cos change their formularies (the list of meds they will cover) all the time.

the first thing i would do is check with your ins co to make sure that abilify is actually not still on the list (pharmacies can make mistakes, just like everyone else). on its website, your ins co should have a copy of their formulary, and if not, i'm sure that they will send one to you if you call and ask.

you might also see if the generic form of abilify -- aripiprazole -- has replaced abilify on the list of approved meds. lots of ins cos won't cover the name-brand form of a med if the generic is available. this is because the price of the name-brand meds is so high compared to the price of the generic versions.

try going thru the ins co appeal process if there is one. if you can't tell from your ins policy whether an appeal process is available, call and ask how to appeal. if there is no appeal process, write a letter appealing the decision, anyway. there is no need to be indignant or self-righteous, just state the facts and ask for reconsideration of the decision.

with an appeal letter, i would bypass the initial bureaucracy and send it to the highest level you can find out about (e.g., manager of meds management, vice-pres for ins policy evaluation, something like that). if necessary, send it to the president of the ins co or the members of its board of directors. no matter how you appeal, if your dr can write a very strong letter supporting you, all the better.

do you get your ins thru your employer, and/or renew it by the year? if so, it may be that their original formulary would be considered part of a contract that can't be changed until it is renewed. check with your employer's dept of human resources about this, or call the ins co, specifically mentioning the possibility that the formulary can be considered part of a contract. unhappily, if you can't get any relief there, you will probably have to consult a lawyer on the contract Q.

in addition, you might consider changing ins cos to find one that covers abilify, altho there will be no guarantee that the same change in formulary won't happen there.

finally, as a last resort, you and your dr might have to talk about a change in meds.

i hope you can get this straightened out; it must be very scary to learn that you can no longer get a psych med that is working for you.

-- susie margaret
marysings responded:
Dr.S once put me on Abilify. My insurance wouldn't cover it either. The cost for one month was $450 . Dr.S gave me samples that got me through a year. He was never able to get the insurance company to cover it.
Loriels responded:
I am going thru the same exact thing. Same med and everything. I used to pay $25 now they want $118.00 I still have the same insurance. Insurance co. said it is not a prefered drug. What now????
grandmastoy responded:
I am 69 years old. I went to get two prescriptions filled that I had taken for awhile. I was told my insurance (Humana) would not pay because it is not recommended for my age. I was only one month older !!
reginahoward replied to grandmastoy's response:
Health insurances vary depending on the company. You must be paid ful of it for you to enjoy your health insurance.

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