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Pharmacy & Formulary

pharmacist

Johns Hopkins Employer Health Programs EHP administers pharmacy benefits for the following groups:

  • Johns Hopkins Hospital/Health Systems
  • Johns Hopkins Bayview Medical Campus
  • Broadway Services Incorporated
  • Johns Hopkins University Student Health Program

For more information:

EHP Formulary
Co-Pay Tier
Generic Substitution
Prior Authorization, Quanitity Limits, and Step Therapy
HealthCare Common Procedure Coding System J Codes

A printed copy of EHP's pharmaceutical management procedures is available to providers upon request. Please call (888) 819-1043, option 4 to request this information.

EHP Pharmacy Formulary

The EHP Pharmacy Formulary (effective 5/1/2015) is a guide for health care providers, plan members and clients. The formulary is updated on a regular basis, including when a new generic or brand-name medication becomes available and as discontinued drugs are removed from the marketplace The EHP formulary is subject to change at any time. Formulary updates will be provided quarterly, as needed and the changes can be found here.

Co-pay Tier

Some EHP Members covered by the EHP pharmacy benefit have a three-tier drug benefit, while others have a four-tier drug benefit.  Each tier has a different co-pay or out-of-pocket expense.

The EHP pharmacy formulary consists of the following tiers:

  • Tier One: Generic drugs have the lowest out-of-pocket cost for members and are placed on Tier 1. Generic drugs are listed in bold in the formulary.
  • Tier Two: Preferred brand-name drugs that have a significant safety or efficacy advantage compared to similar agents. These agents have an intermediate out-of-pocket cost for members.
  • Tier Three: Non-preferred brand-name drugs that do not have a significant, clinically meaningful advantage in terms of effectiveness, safety, and clinical outcomes compared to similar agents. These drugs have higher out-of-pocket cost for members. In most cases, there will be Tier 1 or Tier 2 alternatives for products found in this tier. Brand-name drugs covered under the pharmacy benefit that are not displayed in the formulary or unless otherwise designated by benefit design will process in Tier 3.
  • Tier Four: Tier 4 (highest copay) is not applicable to all EHP employer groups. This tier includes brand drugs for which a generic equivalent is available and select non-preferred brand drugs.

Retail Pharmacy Network:

The retail pharmacy network includes over 64,000 pharmacies nationwide. The network includes most chain retailers and independent pharmacies. Search for a participating network pharmacy near you . Registration is required for first time use.

Generic Substitution

EHP encourages use and prescribing of generic medications. Brand-name drugs with generic equivalents available are placed in Tier 3 of the EHP Formulary. If the prescriber or member chooses a brand name drug with a generic equivalent, the member will be required to pay a higher cost share. Cost share for members covered under the EHP pharmacy benefit vary by employer plan design. Cost share for brand-name drugs with a generic equivalent available is determined by the employer's Summary Plan Description (SPD). Depending on the employer-specific benefit, the member may be required to pay the highest co-pay Tier 3 or pay the highest copay plus the difference in price between the brand and its generic equivalent. To view information on a drug, including how to take the medication, the possible side effects and drug interactions, click here and select Drug Search.

Learn about our Prescribe Thoughtfully program for prescribing providers!

Prior-Authorization, Quantity Limits, & Step Therapy

Prior-Authorization:

Certain medications require prior authorization before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. Coverage of these drugs are subject to specific criteria approved by physicians and pharmacists on the Johns Hopkins HealthCare Pharmacy and Therapeutics Committee. Established criteria are based on medical literature, physician expert opinion, and FDA approved labeling information.

Please refer to the Prior Authorization list in the Pharmacy Formulary. This list is subject to change without notice and is not applicable to all EHP groups. Consult the member's SPD to determine if their plan is subject to this list. Prior Authorization Form

Quantity Limits:

Certain prescription medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the Food and Drug Administration FDA, current medical literature and input from a committee of physicians and pharmacists. The three types of quantity limits include the following:

  • Coverage limited to one dose per day for drugs that are approved for once daily dosing
  • Coverage limited to specific number of units over a defined time frame
  • Coverage limited to approve maximum daily dosage

Please refer to the Managed Drug Limitations (MDL) list in the Pharmacy Formulary.

When medically necessary, an exception to quantity limits can be requested. If your patient's medical condition warrants use of quantities greater than listed quantities for each drug, you may submit a Prior Authorization Form request for a higher quanity.

Prescription drug benefits vary among EHP employer groups; therefore, the information included on this page is for informational purposes only. Certain programs referenced in this information, and in some cases, the pharmacy benefit itself, are not applicable to all EHP employer groups.

Step Therapy:

For some plan members who receive the pharmacy benefit, certain covered medications are required to satisfy specific step therapy criteria. Step therapy criteria simply means that for certain drug products, members must first have tried one or more prerequisite medications to treat their condition before other medications are covered through their benefit.  

Please refer to the Step Therapy (ST) list in the Pharmacy Formulary.

Healthcare Common Procedure Coding System (HCPCS) J Codes

Certain medical injectable medications require prior authorization. To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select diagnoses will be exempt from the prior authorization requirement. Please refer to the specific drug policies to view select exempt diagnoses.

To expedite treatment and claims processing for indications included in FDA labeling or national guidelines, select ICD-9 diagnoses will be exempt from the prior authorization requirement. These diagnoses are listed below.

CodeExempt Diagnoses
J9035 (Avastin)

Antineoplastic Chemotherapy

153.xx MALIGNANT NEOPLASM OF COLON
154.1x MALIGNANT NEOPLASM OF RECTUM
154.8x MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
162.xx MALIGNANT NEOPLASM OF TRACHEA BRONCHUS AND LUNG
189.xx MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
191.xx MALIGNANT NEOPLASM OF BRAIN
183.xx NEOPLASM OF OVARY
174.xx; 175.xx MALIGNANT NEOPLASM OF BREAST

Opthalmic Therapy

362.5x EXUDATIVE SENILE MACULAR DEGENERATION, CYSTOID MASCULAR DEGENERATION
362.07x DIABETIC MACULAR EDEMA
362.2X RETINOPATHY OF PREMATURITY
362.83 RETINAL EDEMA
362.3X RETINAL VASCULAR OCCLUSION

J1745 (Remicade)555.xx REGIONAL ENTERITIS
556.xx ULCERATIVE ENTEROCOLITIS
569.xx OTHER DISORDERS OF INTESTINE
619.1x DIGESTIVE-GENITAL TRACT FISTULA FEMALE
696.0x PSORIATIC ARTHROPATHY
696.1x OTHER PSORIASIS AND SIMILAR DISORDERS
714.0x RHEUMATOID ARTHRITIS
714.1x FELTY'S SYNDROME
714.2x OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
720.0x ANKYLOSING SPONDYLITIS
 
J9310 (Rituxan)200.xx LYMPHOSARCOMA AND RETICULOSARCOMA AND OTHER SPECIFIED MALIGNANT TUMORS OF LYMPHATIC TISSUE
202.0x NODULAR LYMPHOMA
202.4x LEUKEMIC RETICULOENDOTHELIOSIS
202.8x OTHER MALIGNANT LYMPHOMAS
202.9x OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE
204.1x CHRONIC LYMPHOID LEUKEMIA
446.00 POLYARTERITIS NODOSA
446.4x WEGENER'S GRANULOMATOSIS
714.00 RHEUMATOID ARTHRITIS
 

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