[Gabyunbound]

I just got a text from CVS saying that my Abilify is pending insurance approval. I started a new insurance at the beginning of the year and this hasn't happened before.

I'm terrified that if it's not approved, I will become unstable; it's the combination of Abilify and Lamictal (and Seroquel to keep me sleeping well) that has kept me miraculously stable for the last over 2 years now. I'm so scared...

So what do you do if your insurance does not approve a medication? I've never been through this before (of course I'm not sure that will happen, but I want to be prepared if it does). How to you appeal it? What is your pdoc's role in this? The pharmacy's role? What do I do?

Thanks...

I'm in a similar boat. Rexulti is the only thing that's kept me stable, yet my insurance rejected it 5 months ago and rejected it again recently. They really don't want to pay for it!

Anyway, my insurance sent me a letter in the mail telling me why they rejected it, and they listed the criteria I needed to meet in order to get it approved. The criteria was BS, but at least I know.

So imo, check your mail for a letter first. Your pdoc will have to appeal the rejection him- or herself based on the reason that was given. But knowing the reason for rejection can help you work with your pdoc to come up with a game plan.

[Gabyunbound]

Originally Posted by bluebicycle

I'm in a similar boat. Rexulti is the only thing that's kept me stable, yet my insurance rejected it 5 months ago and rejected it again recently. They really don't want to pay for it!

Anyway, my insurance sent me a letter in the mail telling me why they rejected it, and they listed the criteria I needed to meet in order to get it approved. The criteria was BS, but at least I know.

So imo, check your mail for a letter first. Your pdoc will have to appeal the rejection him- or herself based on the reason that was given. But knowing the reason for rejection can help you work with your pdoc to come up with a game plan.

Thanks for your help. How long did this whole process take? I'm afraid that I'll run out of Abilify before it's completed...

Well, my pdoc sent the prescription to Walgreens about 3 weeks ago (Jan 31st) and I got a letter dated Feb 1 from my insurance saying they rejected it, but I didn't get that letter until about the 3rd. So... 4 days? But that's just the notification. We're still trying to appeal the decision. Sorry if that's discouraging. I share your pain!

But you can appeal a couple of times. That's what we've been doing. I mean, it sucks that it's taking so long, but at least you can keep appealing.

I know generic abilify is expensive because I used to be on it, so I know it's not exactly affordable. But try goodrx.com. There are abilify coupons on that website that offset some of the cost. Then you're paying in the range of $20-30 for the med. Might not be a bad option while you're appealing.

[Moreta]

One year my Geodon got rejected because I take more than the FDA limit. It took a month to get it all straightened out. My pdoc ended up sending them a letter with all the meds I have tried and said he was going to sue them if they didn't approve the med. It was rough waiting for it cause I had to cut down my prescription until my pharmacist figured a way to fill at least part of the prescription and that lasted till they got the approval through. Last year though BCBS approved it within a week. I've learned at the beginning of the year to always send in my refill requests a week in advance in case **** like this happens, especially if you've changed insurances.

I hope your med gets approved and it doesn't take a month. You can also ask your pdoc if they have any samples at the office. Sometimes they do. I had to do that when I was taking saphris for a while.

[Wild Coyote]

Your pdoc can appeal as soon as the insurer rejects it. You do not have to wait for a rejection letter to arrive.

My pdoc called my insurer as soon as they rejected a med and they told him what they'd needed. He faxed them a letter accordingly, and immediately. They'd replied within 48 hours, with approvals.

I hope this is the case for you!


WC

[still_crazy]

hi. sorry this is happening. abilify has been generic for a lil while now. I assumed that meant much lower cash prices. I was apparently wrong. The stuff is priced like street drugs!

my only "tip" or whatever is that on my insurance, they flag psych drug duplicates. 2 antidepressants, 2 mood drugs, 2 antipsychotics. When I was all kindsa agitated, my pdoc prescribed a low dose of generic risperidone, to take as-needed/prn. well...that didn't go over well. 1st they denied it, then the pharmacy filled the risperidone w/ coverage but wanted cash for the abilify, and...ugh. it took a while to fix that mess. so, i guess I'm saying...if your coverage is anything like mine, you might want to simplify the situation and try to get the seroquel on a cash pay basis, or ask your doctor about a night time sedative that isn't a tranquilizer/antipsychotic.

sorry about all this. hope this helps. :-)

[beauflow]

I was prescribed abilify... No insurance .. I found coupons through @ https://m.goodrx.com

[Gabyunbound]

Originally Posted by still_crazy

hi. sorry this is happening. abilify has been generic for a lil while now. I assumed that meant much lower cash prices. I was apparently wrong. The stuff is priced like street drugs!

my only "tip" or whatever is that on my insurance, they flag psych drug duplicates. 2 antidepressants, 2 mood drugs, 2 antipsychotics. When I was all kindsa agitated, my pdoc prescribed a low dose of generic risperidone, to take as-needed/prn. well...that didn't go over well. 1st they denied it, then the pharmacy filled the risperidone w/ coverage but wanted cash for the abilify, and...ugh. it took a while to fix that mess. so, i guess I'm saying...if your coverage is anything like mine, you might want to simplify the situation and try to get the seroquel on a cash pay basis, or ask your doctor about a night time sedative that isn't a tranquilizer/antipsychotic.

sorry about all this. hope this helps. :-)

Thanks and actually that's a good point because in any case, the Seroquel isn't working like before for sleep, so I may end up with a non-AP sleep aid anyway. Hope that increases my chances!

[still_crazy]

hi. honestly, not to 2nd guess your shrink (I 2nd guess mine all the time...he's quite patient, lol), but a lot of data available now indicates that, for most people, its best to be on just -1- tranquilizer at a time, and that within an accepted dosage range. true story...with 2+ tranquilizers in the mix, one gets more adverse effects, drug-drug interactions, general un-fun stuff, drug costs go up, and...there's no real benefit, for most people.

besides, id take ambien or restoril over low dose seroquel any day of the week. although...((I have obsessive stuff going on, that's why I know this...) there's been a meta-analysis that found that -regular- sedative usage increased mortality from all sorts of causes, from accidents to various forms of cancer. --shudder-- that inspired me to reduce my sleepy time pill intake, which has been a good thing (For me...).

good luck!

[Tucson]

There is always the appeal process to fall back on. I would get in contact with your insurance about this.

[Guiness187055]

Whenever I have an issue with meds. My doctor fills out a form that says it's medically necessary and I get my meds.

[Wonderfalls]

Originally Posted by still_crazy

hi. honestly, not to 2nd guess your shrink (I 2nd guess mine all the time...he's quite patient, lol), but a lot of data available now indicates that, for most people, its best to be on just -1- tranquilizer at a time, and that within an accepted dosage range. true story...with 2+ tranquilizers in the mix, one gets more adverse effects, drug-drug interactions, general un-fun stuff, drug costs go up, and...there's no real benefit, for most people.

besides, id take ambien or restoril over low dose seroquel any day of the week. although...((I have obsessive stuff going on, that's why I know this...) there's been a meta-analysis that found that -regular- sedative usage increased mortality from all sorts of causes, from accidents to various forms of cancer.

--shudder-- that inspired me to reduce my sleepy time pill intake, which has been a good thing (For me...).

good luck!

I have a carefully crafted mix of medicines that keep me stable and it took us a long time to get there, so I don't mess with it and neither has my new psychiatrist, internist or pdoc I interviewed. I certainly don't expect my insurance to get involved. When they did though my benefits providers (HR or union) dealt with them and won. My psychiatrist at the time would have been my next go-to.

Sadly, I doubt your doctor will have Abilify samples to give out because they're old and off brand protection, unlike Saphris. Just out of curiosity what reasons did your insurance (or anyone's) give for stopping Abilify coverage?

[~Christina]

There is a generic , so unless a person HAS to have Brand then insurance shouldn’t be a problem but if so it would a quick pre approval form the pdocs office staff can do.

[Gabyunbound]

Thanks for all the advice and support guys!

I called my pdoc's office and the nurse there said that they do this all the time and to not worry. He said something about insurance wanting to know how long I've been taking it (don't know why). I told him how long because I wasn't sure my pdoc knew; she's relatively new to me and I don't remember if I ever told her -I came to her already having been on Abilify for a couple of years.

Then I got a call from the person in the office who deals with insurance companies and she also reassured me. She told me that she 'exaggerated' things a bit to get the approval, which I suspect might be pretty par for the course. She told me to call CVS by Saturday and ask them if it had gone through.

If it hasn't by then, I'll call my pdoc's office again. It looks like they're the ones who take care of this whole mess. But I wish I were more in the loop and could help with the process; I know best how important Abilify is to my stability. I did tell the nurse and the person in charge of dealing with insurance companies that its the combination of Lamictal and Abilify that has saved me for the last couple of years. Though I think they had already sent the paperwork. If we have to appeal, I will ask to be able to explain to my pdoc's office why it's so important and that I've tried other meds that did not work as well.

If we have to appeal and it takes a while, I might have to buy a month's worth, but I'll use the coupon that has been suggested (thanks!).

I'm scared as heck, but the support here and from my pdoc's office have helped immeasurably.

[Gabyunbound]

Originally Posted by still_crazy

hi. honestly, not to 2nd guess your shrink (I 2nd guess mine all the time...he's quite patient, lol), but a lot of data available now indicates that, for most people, its best to be on just -1- tranquilizer at a time, and that within an accepted dosage range. true story...with 2+ tranquilizers in the mix, one gets more adverse effects, drug-drug interactions, general un-fun stuff, drug costs go up, and...there's no real benefit, for most people.

besides, id take ambien or restoril over low dose seroquel any day of the week. although...((I have obsessive stuff going on, that's why I know this...) there's been a meta-analysis that found that -regular- sedative usage increased mortality from all sorts of causes, from accidents to various forms of cancer. --shudder-- that inspired me to reduce my sleepy time pill intake, which has been a good thing (For me...).

good luck!

This is really good information, thanks. As I said in another thread, Seroquel (25mg) has stopped working for sleep after a couple of years of being on it at that dose (I used to take it therapeutically -at a much higher dose- but it made me way too sleepy [I was falling asleep at work, etc.]). So I've increased it to 1.5 pills, but still wake up in the middle of the night wide awake. Last night I experimented with taking a klonopin for sleep and it worked really well. I already take 1mg every morning. But I doubt my pdoc will prescribe a benzo for sleep... In any case, I definitely need her help in choosing a non-AP sleep aid, which -as you say and I didn't know all of that- may well help with my overall health as well.

[Gabyunbound]

Originally Posted by still_crazy

hi. sorry this is happening. abilify has been generic for a lil while now. I assumed that meant much lower cash prices. I was apparently wrong. The stuff is priced like street drugs!

my only "tip" or whatever is that on my insurance, they flag psych drug duplicates. 2 antidepressants, 2 mood drugs, 2 antipsychotics. When I was all kindsa agitated, my pdoc prescribed a low dose of generic risperidone, to take as-needed/prn. well...that didn't go over well. 1st they denied it, then the pharmacy filled the risperidone w/ coverage but wanted cash for the abilify, and...ugh. it took a while to fix that mess. so, i guess I'm saying...if your coverage is anything like mine, you might want to simplify the situation and try to get the seroquel on a cash pay basis, or ask your doctor about a night time sedative that isn't a tranquilizer/antipsychotic.

sorry about all this. hope this helps. :-)

I will definitely be asking my pdoc for a non-AP sleep aid. Though I don't understand why insurance companies get like that over an extra AP that is taken at a sub-threshold (non-therapeutic/low/only for sleep) dose. I'm tired of my new insurance trying to control my healthcare: they already denied an MRI which I really need and which is being appealed.

[RomanJames2014]

The same happened for my Abilify when my Insurance switched over but the doctor will be able to fight for it and with the change of dosage Abenaki that it might work out fine. The insurance companies and CVS just take precaution.

I went to finally pick mine up and the pharmacist “needed to speak with me”. It scared me but she just wanted to stress when to take and how to take the Abilify.

Without the insurance CVS wanted to charge me $865.00 and since I’m negative in the bank right now that wasn’t able to happen so I’m glad my pdoc was able to work it out. He changed my dosage to 30 5mg tables that I split in half.

Originally Posted by Gabyunbound

Thanks for all the advice and support guys!

I called my pdoc's office and the nurse there said that they do this all the time and to not worry. He said something about insurance wanting to know how long I've been taking it (don't know why). I told him how long because I wasn't sure my pdoc knew; she's relatively new to me and I don't remember if I ever told her -I came to her already having been on Abilify for a couple of years.

Then I got a call from the person in the office who deals with insurance companies and she also reassured me. She told me that she 'exaggerated' things a bit to get the approval, which I suspect might be pretty par for the course. She told me to call CVS by Saturday and ask them if it had gone through.

If it hasn't by then, I'll call my pdoc's office again. It looks like they're the ones who take care of this whole mess. But I wish I were more in the loop and could help with the process; I know best how important Abilify is to my stability. I did tell the nurse and the person in charge of dealing with insurance companies that its the combination of Lamictal and Abilify that has saved me for the last couple of years. Though I think they had already sent the paperwork. If we have to appeal, I will ask to be able to explain to my pdoc's office why it's so important and that I've tried other meds that did not work as well.

If we have to appeal and it takes a while, I might have to buy a month's worth, but I'll use the coupon that has been suggested (thanks!).

I'm scared as heck, but the support here and from my pdoc's office have helped immeasurably.

The insurance wants to know how long you've been taking it because they don't want to waste their time listening to your pdoc make an argument about destabilizing you. They know your pdoc will argue that going off the med will destabilize you, so they're just cutting out a step and asking it upfront. Basically, "ok, we know you're going to argue about us destabilizing the patient, so just tell us how long they've been taking it. Then we'll decide if the length of time they've been on it will cause destabilization when they go off it." (Insurance companies have doctor's who are trained in certain areas of medicine, including psych medicine, so you are at these doctors' mercy.)

And yep, most doctors exaggerate. It's unfortunately the only way to go. Complete honesty means nothing to insurance companies because they'll find any excuse not to cover the med. Most of them are for-profit and they don't make money by giving everyone exceptions.