Request For Appeal Of Medicare Prescription Drug Denial
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4Request for Appeal of Medicare Prescription Drug Denial
Because we, Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan), denied your request for
payment of a drug, you have the right to ask us for an appeal of our ruling. You have 60 days
from the date of our Notice of Denial of Medicare Prescription Drug Coverage to do so. The
form may be mailed or faxed to us:
Address:
Fax Number:
MMP Appeals and Grievances
1-855-856-1724
PO Box 61116
Virginia Beach, VA 23466
You may also ask for an appeal on our website at Rushed
appeal requests can be made by phone at 1-855-878-1784 (TTY users call: 711), 8 a.m. to 8 p.m.
local time.
Who May Make a Request: Your prescriber may ask us for an appeal for you. If you want some
other person (such as a relative or friend) to ask for an appeal for you, that person must be
your agent. Talk with us to learn how to name an agent.
Y0005_H8786_15_23633_R CMS Approved 4/9/2015
MF-TXD-0009-15-U
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