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Pharmacy Transition Plan

What if a drug you take now isn’t on our Drug List?

We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a participant of the Amerigroup STAR+PLUS MMP. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

Part D drugs

We will cover a 31-day supply of your drug if:

  • You are taking a drug that is not on our Drug List, or
  • Health plan rules do not let you get the amount ordered by your prescriber, or
  • The drug requires prior approval by Amerigroup STAR+PLUS MMP, or
  • You are taking a drug that is part of a step therapy restriction.
Live in a nursing home or other long-term care facility?

If you live in a nursing home or other long-term care facility, you may refill your prescription for up to a maximum 98-day supply of medication within your first 90 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception.

Non-part D Drugs

For drugs that aren’t Part D drugs, all prior approvals and therapies you’re currently getting at the time of enrollment will be honored for 90 days after enrollment. We will notify you before that time is up so you can work with your provider to identify a different course of treatment (such as therapeutic alternatives) or at least have time to ask for an exception. In the Drug List, non-Part D drugs have an asterisk (star) next to them. These rules apply to both Medicaid- and Medicare-covered drugs and therapies.

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.

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.

What is the Office of the Ombudsman?

The Managed Care Office of the Ombudsman helps solve problems from a neutral standpoint to ensure that our members receive all medically necessary covered services for which plans are contractually responsible.

What does the Office of the Ombudsman do?

  • Serves as an objective resource to resolve issues between managed care members and managed care health plans
  • Conducts impartial investigations of member complaints about managed care health plans
  • Helps members with urgent enrollment and disenrollment problems.
  • Offers information and referrals
  • Identifies ways to improve the effectiveness of the managed care program
  • Educates members on how to effectively navigate through the managed care system
  • Assisting consumers in filing appeals, including utilization review appeals
  • Ensuring consumers have access to the Office and receive timely responses

Hours of operation: Monday through Friday from 8 a.m. to 5 p.m.
By phone: 1-877-787-8999
TTY: 711
By mail: Texas Health and Human Services Commission Office of the Ombudsman, MC H-700
PO Box 13247
Austin, TX 78711-3247
Website: Ombudsman

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