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Plans & Benefits: Texas STAR+PLUS

Helping you manage all the moving pieces

Health care can be overwhelming, so we’re here to help you stay on top of it. We’re a health plan in the Texas STAR+PLUS program serving:

  • People ages 65 and over
  • People with disabilities, ages 21 and older
  • People who get Supplemental Security Income (SSI), ages 21 and older
  • Women ages 18-64 in the Medicaid Breast and Cervical Cancer (MBCC) program

Our service coordinators help make sure all your care and services work together — especially if you have both Medicare and Medicaid. They’ll work with you to create your own care plan and help you get the services you need to be healthy and to live as independently as possible.

Benefits beyond what you expect

We’re about more than just doctor visits. Our extras are designed to make a difference in your life:

  • Real Solutions® Healthy Rewards debit card dollars for meeting health goals or getting certain checkups or screenings
  • Help from a nurse anytime — day or night, with our 24-hour Nurse HelpLine
  • Free cellphone with monthly minutes and texts for those that qualify
Extras to help you at home
  • Pest control services every 3 months
  • 8 hours of respite services each year for families and caregivers
  • Rides to doctor visits when state services aren’t available (members with Medicare will get rides to Medicaid-covered long-term services and supports)
  • Home-delivered meals after getting out of a hospital or nursing facility
  • Free first aid kit when you complete a disaster plan online
Extras to help you be well
  • Enhanced vision benefits
  • Personal exercise kit
  • Dental hygiene kit
  • Help to quit smoking
  • Taking Care of Baby and Me® program for pregnant women and new mothers
Extras for nursing facility members
  • A personal remembrance photo album
  • Personalized labels for belongings

Exclusions and limitations apply. Read your member handbook to learn more about benefit details and which ones you can get.

Your health benefits


Acute care

Acute care includes things like:

  • Routine doctor visits
  • Preventive and specialist care
  • Hospital care
  • Prescriptions
  • Behavioral health services
  • Rides to doctor appointments

You’ll see your primary care provider for most of your care.

  • If you only have Medicaid, you’ll choose a primary care provider in our plan and we’ll provide your acute care benefits.
  • If you have both Medicare and Medicaid, you’ll choose a primary care provider in your Medicare plan. Your Medicare plan will provide your acute care benefits.
Long-term services and supports

If you have trouble with everyday tasks like dressing yourself, preparing meals, light housekeeping, or personal care, long-term services and supports can help you live in your own home or community.

The kind of help you can get is based on the Medicaid eligibility category you’re in:

  • Other Community Care (OCC) — basic benefits
  • Community First Choice (CFC) — mid-level benefits
  • Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) — high-level benefits for members with complex health needs

The Texas Department of Aging and Disability Services (DADS) provides long-term services and supports for STAR+PLUS members, who:

  • Have an intellectual disability or related condition and
  • Receive services through the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Condition (ICF-IID) program or an Intellectual or Developmental Disability (IDD) Waiver

IDD Waivers include:

  • Community Living Assistance and Support Services Waiver program (CLASS)
  • Deaf-Blind with Multiple Disabilities Waiver program (DBMD)
  • Home and Community-Based Services Waiver program (HCBS)
  • Texas Home Living Waiver program (TxHmL)

In order to get long-term services and supports, you must first meet with your service coordinator to talk about the kinds of help you may need. Read the member handbook to learn more about available benefits.

If you get benefits through MBCC, you’ll have a service coordinator, and you may be able to get Home and Community-Based Services.

Vision care

If you only have Medicaid, you have vision benefits. Learn more about them in the member handbook.

If you have Medicare and Medicaid, read the materials from your Medicare plan to learn about your vision benefits.

Dental care
  • If you’re a Home and Community Based Services (HCBS) STAR+PLUS Waiver (SPW) member, talk to your service coordinator about dental services.
  • If you have Medicare, contact your plan to learn about dental services.
  • If you only have Medicaid and aren’t a SPW member, we only cover emergency dental services.
STAR+PLUS nursing facility members

If you live in a nursing facility, most of your care will come from the nursing facility.

Services include:

  • Daily care services, like
    • Room and board
    • Medical supplies and equipment
    • Personal needs items
    • Social services
    • Over-the-counter drugs
  • Nursing facility add-on services, which include:
    • Emergency dental services
    • Physician ordered-rehabilitative services
    • Augmentative communication devices
    • Customized power wheelchairs
    • And more
Costs for STAR+PLUS benefits

You don’t pay anything, including copays, for your STAR+PLUS Medicaid benefits.

Check with your Medicare plan about copays for Medicare benefits.

If you’re a STAR+PLUS nursing facility member:

  • You pay nothing except the monthly applied income amount you pay to the nursing facility.
  • If you have Medicare, we pay your percentage of the costs for a Medicare-covered stay for nursing facility daily care services. Your Medicare plan or Texas Medicaid pays your percentage of the costs for nursing facility add-on services.
Service Coordination

Service coordination helps make sure all your care and services are working together. By communicating regularly with you and your providers, service coordinators help to keep everyone involved in your care informed of your needs and goals. Your service coordinator will work with you and your primary care provider to help you get needed services. He or she will also:

  • Visit you at your home to learn about your health needs and goals and help create your service plan.
  • Help you make appointments to see your providers and help you get covered services when you need them.
  • Help you get authorizations for needed services.
  • Coordinate all of the services you get from us and other providers and community organizations.
  • Encourage you to take part in your care, so you can stay healthy and live independently.

You can have a service coordinator if you ask for one. We may also assign one after we look at your health and support needs. If you think you need a service coordinator or if you’d like to speak with one, call Member Services at 1-800-600-4441 (TTY 711).

Eligibility & Enrollment

You may be able to get STAR+PLUS benefits if you’re age 21 or older, can get Medicaid, and one of the following applies:

  • You get Supplemental Security Income (SSI)
  • You have a disability
  • You’re eligible for STAR+PLUS Home and Community-Based Waiver services
  • You get Medicaid through Social Security Exclusion programs
  • You live in a nursing home
  • You’ve been diagnosed with breast or cervical cancer and can get services through the Medicaid Breast and Cervical Cancer (MBCC) program

To find out if you’re eligible, either:

To apply:

After you’re approved, you’ll get an enrollment package from HHSC. You’ll have 15 days to choose a health plan. Call the STAR+PLUS Help Line at 1-800-964-2777 to join Amerigroup.

Pharmacy: Your prescription drug benefits

We work with Express Scripts (ESI) to provide your pharmacy benefits.

You don’t have pharmacy copays.

If you have both Medicare and Medicaid, contact your Medicare Part D plan to learn more about pharmacy benefits.

To learn more about your pharmacy benefits, refer to the member handbook.

Getting your prescription filled is easy!

You can go to any pharmacy in our plan. Use the pharmacy locator tool to find a pharmacy close to you

  • Give the pharmacist your written prescription or have the doctor call it in
  • Show your Amerigroup ID card or Your Texas Benefits Medicaid card
    • If you have Medicare, show your Medicare Part D card to the pharmacist

It’s a good idea to use the same pharmacy for all your prescriptions. This way the pharmacist will know what medicines you’re taking and can tell you about any problems or drug interactions that could occur. If you use more than one pharmacy, tell them about all medicines you take.

Drug Coverage Information

Your doctor chooses drugs from the State Vendor Drug Program (VDP) list of drugs. It includes all medicines covered by Medicaid.

View the State Vendor Drug Program list

Prior authorization (preapproval)

Your doctor may need to get preapproval from us for certain drugs before prescriptions are filled.

To ask for an exception, email us at
wrkgp-submitmyexceptionreq@anthem.com.

When there is a generic drug available on the VDP list, it will be covered in place of the brand-name drug. Generic drugs are equal to brand-name drugs as approved by the Food and Drug Administration (FDA).

Searchable Formulary

Search for name brand and generic drugs in the formulary

Drug Interactions and Side Effects

Learn more about drug interactions or side effects at the ESI Drug Information website

Express Scripts Prescription Drug Reimbursement Form

If you paid out-of-pocket for a prescription drug, you can ask us to pay you back. Please use the form below to request reimbursement.

Manage your prescriptions online

ESI online registration instructions:

Pharmacy: Frequently asked questions

What pharmacies are in the Amerigroup plan?

There are many chain and local pharmacies in our plan to choose from. You can find one by:

How do I transfer my prescriptions to a pharmacy in the plan?

If you need to transfer prescriptions:

  • Call a pharmacy in our plan and tell the pharmacist you want to transfer a prescription
  • Bring your prescription container to the new pharmacy and they will handle the rest

How does my provider request preapproval?

Your doctor can request preapproval by:

  • Faxing a completed prior authorization (preapproval) form to
    1-800-601-4829
  • Calling the Amerigroup Pharmacy department at 1-855-215-4496

What if a copay is required and I’m unable to pay it?

You don’t have pharmacy copays.

If you have both Medicare and Medicaid, contact your Medicare Part D plan to learn more about pharmacy benefits.

How do I get my medicine if I’m traveling?

We have pharmacies in our plan in all 50 states. Call your doctor for a new prescription to take with you on vacation.

What happens if my child’s medicines are lost or stolen?

If your medicines are lost or stolen, call the doctor and ask him or her to call your pharmacy to authorize an early refill. The pharmacy may have to contact our Prior Authorization Desk for approval. We will review lost or stolen medicines on a case-by-case basis.

What if I paid out of pocket for a medicine and want to be reimbursed?

If you had to pay for a medicine, you may submit a request for reimbursement form. You’ll need to mail the completed Express Scripts Prescription Drug Reimbursement Form; Spanish form along with any receipts to:

Amerigroup
Pharmacy Department
PO Box 62509
Virginia Beach, VA 23466-2509

FAQs

Find answers to your questions below.

Q: Who can get services through the Medicaid Breast and Cervical Cancer (MBCC) program?

A: MBCC provides Medicaid services to women diagnosed with breast or cervical cancer, or certain pre-cancerous conditions. You can get MBCC services if you’re:

  • Uninsured
  • Between age 18 and the month you turn 65
  • A U.S. citizen or qualified immigrant
  • A Texas resident
  • At or below 200% of the federal poverty income level

Men aren’t eligible for MBCC. Women will need to show eligibility every six months by:

  • Submitting proof of active treatment for breast or cervical cancer from the treating doctor (form H1551, treatment verification) and
  • Submitting a completed MBCC renewal form (form H2340)

Q: What services am I eligible for as a Medicaid Breast and Cervical Cancer (MBCC) member?

If you’re enrolled through the Medicaid Breast and Cervical Cancer program, you get all STAR+PLUS benefits. You aren’t limited to just services to treat cancer.

Q: Can I keep seeing my current doctors?

A: Yes, if they’re part of our plan. If not, you may be able to keep seeing your current doctors for up to 90 days for acute care services. You may be able to keep seeing your LTSS providers for up to 180 days. Call Member Services and ask us to approve for you to keep seeing your current doctors.

Do I have to choose a health plan?

Yes, you must choose a health plan in your area or the Health and Human Services Commission (HHSC) will assign you to one. To learn more, call the STAR+PLUS Help Line at 1-800-964-2777. You can change your health plan once a month.

Can I keep the same doctor?

Yes, as long as he or she is in our plan. Check the Find a Doctor page to see if your doctor is in our plan.

Can I see a doctor who isn’t in my plan?

In most cases, you’ll need to see a doctor in the Amerigroup plan. If you think you need to see a doctor outside the plan, please call Member Services. In an emergency, you can see any doctor or go to any hospital.

How do I switch my primary care provider?

To change your primary care provider (PCP), you may:

  • Log in to your secure account and follow the instructions to Change PCP
  • Call Member Services and we’ll make the change for you

The change will start right away, and you’ll get a new ID card in the mail within 10 business days. If you need help choosing a new doctor, use our Find a Doctor tool.

Will I lose my benefits if I switch my primary care provider?

No, you won’t lose any benefits as long as your new doctor is in our plan.

I have Medicare. What plan is my primary care provider in?

If you have Medicare, your primary care provider is from your Medicare plan. If you have questions about your medical, behavioral health, or prescription drug benefits, call your Medicare plan or your primary care provider.

Are prescription drugs covered?

Yes, we use the Texas State Vendor Drug Program (VDP) list of drugs for your doctor to choose from. You can go to any pharmacy in our plan to have your prescriptions filled.

If you have Medicare, your Medicare Part D coverage will be used first to cover your medicine. If Medicare doesn’t cover your medicine, Medicaid pays for most medicines your doctor prescribes.

How do I replace my Amerigroup ID card if it is lost or stolen?

If your ID card is lost or stolen, call us right away at 1-844-756-4600 (TTY 711). We’ll send you a new one. You may also print your ID card from our website. You’ll need to register and log in to the website to access your ID card information.

How can I get a new ID card, member handbook, or provider directory?

You can:

  • Log in to your account to print a new ID card or download a copy of the member handbook
  • Download a copy of a provider directory from the Find a Doctor page
  • Call Member Services and ask for a new ID card, member handbook, or provider directory to be mailed to you

If I don’t have my card, can I still go to the doctor?

If you don’t have your member ID card, tell your doctor’s office Amerigroup is your health plan. They should be able to help you. If you have the Your Texas Benefits ID card, be sure to show it.

Who do I call if I have concerns about my health-care benefits?

Call Member Services or your service coordinator.
If you have health-related questions, call our 24-hour Nurse HelpLine at 1-800-600-4441 (TTY 711). You can speak to a nurse anytime — 24 hours a day, 7 days a week.

What is preapproval?

Some treatment, care, or services may need our approval before your doctor can provide them. This is called preapproval. Your doctor will work directly with us to get the approval. The following require preapproval:

  • Most surgeries, including some outpatient surgeries
  • All elective and nonurgent inpatient services and admissions
  • Chiropractic services
  • Most behavioral health and substance abuse services (except routine outpatient and emergency services)
  • Certain prescriptions
  • Certain durable medical equipment, including prosthetics and orthotics
  • Certain gastroenterology procedures
  • Digital hearing aids
  • Home health services
  • Hospice services
  • Rehabilitation therapy (physical, occupational, respiratory, and speech therapies)
  • Sleep studies
  • Out-of-area or out-of-network care except in an emergency
  • Advanced imaging (things like MRAs, MRIs, CT scans, and CTA scans)
  • Certain pain management testing and procedures
  • Long-term services and supports

This list is subject to change without notice and isn’t a complete list of covered plan benefits. Learn more about your benefits by:

  • Reading your member handbook
  • Calling Member Services with questions about specific services

Amerigroup members in the Medicaid Rural Service Area and the STAR Kids program are served by Amerigroup Insurance Company; all other Amerigroup members in Texas are served by Amerigroup Texas, Inc.