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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.

To get a temporary supply of a drug, you must meet the two rules below:

1. The drug you have been taking:

  • is no longer on the plan’s Drug List, or
  • was never on the plan’s Drug List, or
  • is now limited in some way.

2. You must be in one of these situations:

  • You were in the plan last year.
    • We will cover a temporary supply of your drug during the first 90 days of the calendar year.
    • This temporary supply will be for up to 31 days.
    •  If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31 days of medication. You must fill the prescription at a network pharmacy.
    • Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.
  • You are new to the plan.
    • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan.
    • This temporary supply will be for up to 31 days.
    • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31 days of medication. You must fill the prescription at a network pharmacy. Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.
  • You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away.
    • We will cover one 34-day supply, or less if your prescription is written for fewer days. This is in addition to the above temporary supply.
    • To ask for a temporary supply of a drug, call Pharmacy Member Services at 1-833-232-1711 (TTY: 711) 24 hours a day, 7 days a week.

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 Pharmacy Member Services toll-free at 1-833-232-1711 (TTY: 711) 24 hours a day, 7 days a week. We will work with you and your provider to help you ask for an exception. For more information, review your Member Handbook.

First, we must receive a statement from your doctor or other 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 04/03/2020
H8786_20_117495_R CMS Approved 02/10/2020