Determinations & Exceptions

What is a coverage determination?

A coverage determination is a decision we make about your benefits or coverage or about the amount we will pay for services. Read more about exceptions.

What is an exception and how do I ask for one?

You can ask Amerigroup STAR+PLUS MMP to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.

For example, Amerigroup STAR+PLUS MMP may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

How to ask for an exception

To ask for an exception, call Member Services. Member Services will work with you and your provider to help you ask for an exception.

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

You have the right to ask for an appeal if you don’t agree with our decision.

Updated – 1/25/2017
H8786_17_30140_R CMS Approved 01/23/2017