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Pharmacy Transition Plan

If you take a drug that isn’t listed on our Drug List, we may cover a temporary 31-day supply of your drug during the first 90 days of your membership in Amerigroup STAR+PLUS MMP. This will give you time to talk to your doctor to decide if you should switch to another drug on the Drug List or to ask for an exception.

Part D drugs

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

  • You’re taking a drug that is not on our Drug List, or
  • Health plan rules don’t allow you to get the amount ordered by your prescriber, or
  • The drug requires prior approval by Amerigroup STAR+PLUS MMP, or
  • You’re taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility:

We’ll cover up to a maximum 93-day supply of medication within your first 90 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 93-day supply of medication. 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 getting at the time of enrollment will be honored for 90 days after enrollment. We’ll 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 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.

Examples:

  • There may be limits on 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.
  • You can ask us to drop step therapy restrictions (a requirement to try a different drug first) or prior approval requirements.

How to ask for an exception

Call Member Services at 1-855-878-1784 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. We 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 7/24/2018
H8786_18_35300_R CMS Approved 8/16/2018