Limits on medications which are not manufacturer or FDA regulations

[Lee272]

My insurance company places limits on certain medications such as Ambien. It will only allow fifteen pills per month. My grandmother takes the same medications and has no trouble getting her full prescription. Is there a mental health element involved in these limitations? If so it is discrimination. The limitations are not a FDA regulation because I have talked to them three times. I have talked to the drug manufacturers, it is not their limits either. Is there a mental health component is companies putting these restrictions on medication. If there is I would like to fight it because it is illegal and discriminatory.

[LeftCoastChick]

I'm limited even in Canada by my provate insurance company for certain drugs, like my Nexxium. I'm only allowed to get 28 tablets at a time, from what I know, since the insurance is paying for some or all of the drug, they can set the guidelines. My gov't insurance won't even cover Lamactil or Nexxium, but my private does! go figure.

[ILADVOCATE]

If you told me the name of the specific form of insurance I could tell you how to appeal it. As for more limitations on mental health coverage than physical health coverage as you may know the mental health parity law was passed recently and will go into effect in January 2010 so after that it will be specifically against the law. But if there are regulations on specific medications independent of mental health, within your healthcare plan I would appeal the denial and see if you could be granted an exemption.

[tres1965]

My Fathers insurance company pays only for 20 pills per month,
my ins co. pays for only 30, my friends ins. co pays for 31 each
month....sorry, I don't think it is against the law, but I can't be sure
of that legally...

[monkeyc]

correct me if I am wrong but under the US system a HMO can set what ever rules it likes past certain basic guidelines?

I think you medical system is a mess, its a world where the sick cannot see doctors and mentally ill patients end up in prison because they had no access to drugs or therapy.  But sadly I do not see anything illegal or discriminatory here - the insurance company sets the rule.

Cant you find another HMO?