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Johns Hopkins Health Plans

Pharmacy & Formulary

Johns Hopkins Advantage MD administers Part D Pharmacy Benefits for the following members:

  • Johns Hopkins Advantage MD (PPO)
  • Johns Hopkins Advantage MD Plus (PPO)
  • Johns Hopkins Advantage MD Premier (PPO)
  • Johns Hopkins Advantage MD Primary (PPO)
  • Johns Hopkins Advantage MD Group (PPO)
  • Johns Hopkins Advantage MD (HMO)
  • Johns Hopkins Advantage MD D-SNP (HMO)
  • Johns Hopkins Advantage MD Select Virginia (HMO)

Formularies
Cost Sharing Tier
Prior Authorization, Quantity Limits, and Step Therapy
Select Insulins for Reduced Copays
Exceptions
Appeals (Redetermination)
Opioid Edits
Medical Injectables
Over the Counter Program

Important Message About What Members Pay for Part B Drugs – Johns Hopkins Advantage MD (HMO/PPO) members will pay less for many Part B drugs. The decrease in price will affect Part B rebatable drugs that have increased at a rate faster than the rate of inflation. Changes to co-insurance amounts are subject to change each quarter. Advantage MD will not charge more than $35 for one-month’s supply of insulin furnished through an item of durable medical equipment (example: insulin pump).

Advantage MD Pharmacy Formularies

The Comprehensive Formularies are complete lists of medications we cover and are approved by Medicare. Our formularies are updated on a monthly basis or whenever formulary changes occur.

Advantage MD utilizes multiple formularies. The member’s plan determines which formulary applies:

Advantage MD PPO/Plus PPO/Premier PPO Formulary
Advantage MD Primary (PPO)
Advantage MD HMO Formulary
Advantage MD D-SNP (HMO) Formulary
Advantage MD Select Virginia (HMO) Formulary

Formulary Changes

The Advantage MD formularies are subject to change at any time upon Medicare approval. Formulary changes will be reflected in the updated formularies and in the formulary changes lists below.

PPO/Plus PPO/Premier PPO Errata (list of formulary changes)
HMO/Primary PPO Errata (list of formulary changes)
D-SNP (HMO) Errata (list of formulary changes)

Formulary Search

You may also search for a specific drug in one of our formularies using our formulary search tools. The searchable formulary may not include all covered drugs. Please see the most recent comprehensive formulary document for verification of formulary status.

PPO/Plus PPO/Premier PPO formulary search tool
HMO/Primary PPO formulary search tool
D-SNP (HMO) formulary search tool
Select Virginia (HMO) formulary search tool

Prior Authorization, Quantity Limits, and Step Therapy

Advantage MD plans, except DSNP, allows 100-day supplies on Tier 1 maintenance medications for the same cost as a 90-day supply.  Please consider prescribing generic blood pressure, cholesterol, and diabetes medications as 100-day supplies to help your patients save money and improve their adherence.

The search results and formulary drug list will indicate if any prior authorizations, quantity limits, or step therapy requirements apply.

Medications that have special requirements for coverage are identified in the formulary with the following indicators:

  • PA - Prior authorization required
  • QL - Drug has a quantity limit
  • ST - Step therapy required
  • NM - Not available at mail-order pharmacies
  • LA - Limited Access, available only at certain pharmacies per manufacturer’s restriction.
  • B/D - This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
  • * Not available as extended days' supply (greater than 30 days' supply)
  • GC - We provide additional coverage of this prescription drug in the coverage gap.
  • EX - This prescription drug is not normally covered in a Medicare Prescription Drug Plan
  • V/I (Vaccine/Insulin)- This drug's Tier Copay may not apply to the member. Our plan covers most Part D vaccines at no cost. Our plan covered insulin is no more than $35 for a one-month supply

Reduced Copays for Insulins

Advantage MD plans offers reduced copays on insulins.  Cost savings will apply to covered insulin products during the initial, coverage gap, and catastrophic stages. Member cost share for covered insulins will be $35 for a one-month supply and up to $105 for a three-month supply with additional savings for mail order. Providers are encouraged to prescribe formulary insulins.

Cost Sharing Tiers

Our HMO and PPO formularies consist of the following cost sharing tiers:

Cost Sharing Tier 1: Preferred Generic Drugs have the lowest out-of-pocket cost for members and are placed on Tier 1. Generic drugs are listed in italic type in the formulary.

Cost Sharing Tier 2: Generic Drugs have a low out-of-pocket cost for members. Some low-cost preferred brands are also included.

Cost Sharing Tier 3: Preferred Brand Drugs have an intermediate out-of-pocket cost for members. Some non-preferred generic drugs are also included.

Cost Sharing Tier 4: Non-Preferred Drugs have a higher out-of-pocket cost for members.

Cost Sharing Tier 5: Specialty Tier Drugs have the highest out-of-pocket cost for members.

Copays increase from Preferred Generic to Specialty Tier Drugs. Maintenance medication on cost sharing tier 1 may be obtained for a 100 day supply and medications on cost sharing tier 2 through tier 4 may be obtained for a 90 day supply. Specialty Tier drugs have a coinsurance and are limited to a 30 day supply.

Our DSNP formulary processes all drugs at tier 1.

Advantage MD utilizes multiple formularies which have different cost sharing tiers. The member’s plan determines which benefit and formulary applies. Please note: the same drugs may not be in all formularies and the drugs may be on different tiers (Tier 2 vs. Tier 3). Please review the applicable formulary and corresponding cost sharing tiers (copays) to confirm coverage.

Retail Pharmacy Network

The retail pharmacy network includes over 65,000 pharmacies nationwide. The network includes most chain retailers and independent pharmacies. CVS/caremark mail order pharmacy provides mail order requests to members. The plan’s website includes a pharmacy locator for members and providers to easily locate participating pharmacies.

Mail Order Pharmacy Program

Mail Order Best Practices

One of the most important ways to improve the health of our members is to make sure they receive and take their medications as you prescribe. Our mail order pharmacy, CVS/caremark, can help. CVS/caremark sends a three month supply of maintenance medications in one fill, making it easier for the patient only having to fill four times a year. In addition, a three month supply of maintenance medication on Tier 1 through 4 is available through CVS/caremark mail order at a reduced copay. This means your patient can fill a 100-day supply of Tier 1 medication and a 90-day supply of Tier 2 through 4 medication for only 2 times the retail copay—saving them an equivalent of four retail copays per year. Talk to your patients today about mail order pharmacy with CVS/caremark for better health and health care spending. Doctors and staff can contact CVS/caremark by calling the number below, 24 hours a day, seven days a week.

PPO members: 877-293-5325
HMO members: 877-293-4998

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 Medicare. Established criteria are based on medical literature, physician expert opinion, and Food and Drug Administration (FDA) approved labeling information.

PPO Prior Authorization Criteria
HMO/Primary PPO Prior Authorization Criteria
D-SNP (HMO) Prior Authorization Criteria

Quantity Limits

Certain 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 FDA, and current medical literature, and are approved by Medicare. To find the quantity limit for certain medications, please refer to the appropriate formulary/formulary search tool.

Step Therapy

Certain 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. To find if a drug requires a Step Therapy and criteria, please refer to the appropriate formulary/formulary search tool.

PPO Step Therapy Criteria
HMO Step Therapy Criteria
D-SNP (HMO) Step Therapy Criteria

Exceptions

  • Formulary Exceptions can be requested when a medical condition warrants use of certain medications not on the formulary. Clinical documentation should be provided to support all requests.
  • Quantity Exceptions can be requested when a medical condition warrants use of quantities greater than listed quantities for each drug. Clinical documentation should be provided to support all requests.
  • Step Therapy Exceptions can be requested when there is contraindication to the prerequisite medication or there is documented trial and failure of prerequisite medication.
  • Tier Exceptions can be requested to provide the drug at a lower cost-sharing tier when the drugs at a lower copayment level have been tried and failed or are contraindicated. Tier 5 (Specialty Tier) medications are exempt from tier exception. Clinical documentation should be provided to support all requests.

How to request Prior Authorization, Step Therapy Exception, Quantity Exception, Formulary or Tier Exception when medically necessary

Appeals (Redetermination)

If a request is denied, an appeal or a redetermination may be filed within 60 calendar days from the date of the first decision.

Vaccine Coverage

Advantage MD provides coverage for a number of Part B and Part D vaccines. Covered Part D vaccines are available at the pharmacy for no cost to members. Please refer to the pharmacy prescription benefit section of the Provider Manual or the plan's member website vaccine coverage page.

Medicare Part B vs. Part D Drugs

Johns Hopkins Advantage MD covers both Medicare Part B and Part D medications. Diabetes testing supplies are covered under Medicare Part B. Supplies like meters, lancets, and test strips can be purchased at a network pharmacy, but nebulizers and other equipment must be purchased through a DME vendor. For a complete comparison of which medications are covered by which part, please refer to the Medicare Part B vs. Part D chart. If you have any questions, call Customer Service:

PPO patients: 877-293-5325
HMO and D-SNP patients: 877-293-4998

Opioid Safety Edits

The following edits will occur at point-of-sale at the pharmacy:

  • Seven-day Opioid Naïve Edit
    • In the CMS 2019 Call Letter, all Part D sponsors are required to implement a safety edit reject to limit initial opioid prescription fills for the treatment of acute pain to no more than a seven days supply. Therefore, if an opioid naïve patient attempts to fill more than a seven days supply of an opioid, the prescription will reject at the pharmacy.
    • Exemptions to this are patients with a cancer diagnosis, residence in a Long-Term Care facility, Hospice, Palliative Care, and patients who are not opioid naïve.
    • Pharmacies may request opioid prescribers to submit a Coverage Determination for prescriptions for opioid naïve members when days supply exceeds seven days.
  • Cumulative Morphine Milligram Equivalent (cMME) Edit (aka Care Coordination Edit)
    • This rejection will occur if the cMME dose is greater than 90mg and the Part D Enrollee has received opioid prescriptions from four or more prescribers in the previous 108 days.
    • This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation or request prescribers to submit a Coverage Determination.
  • Duplicate Long-Acting Opioid Edit
    • This rejection will occur when prescribed drugs have the same therapeutic effects as medication(s) the Part D Enrollee is currently taking (i.e. member is filling two or more long-acting opioids).
    • This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation.
  • Opioid/Benzodiazepine Drug Interaction Edit
    • This rejection will occur when interacting drug combinations are identified (i.e. member is filling opioids and benzodiazepines).
    • This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation.

Johns Hopkins Advantage MD expects that network prescribers respond to pharmacy outreach related to opioid safety alerts in a timely manner. This includes expecting network prescribers to educate their on-call staff on how to respond to inquiries by the pharmacist during non-office hours. These point-of-sale edits are safety edits and not intended as prescribing limits.

Medical Injectables

Advantage MD requires prior authorization and/or step therapy for certain provider-administered medications to determine medical necessity. Advantage MD is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent, objective medical criteria. Step Therapy requires preferred products be used prior to non-preferred agents. The provider may request an exception to the step therapy for specific circumstances that warrant a need for a non-preferred product.

It is the ordering provider’s responsibility to determine which specific codes require prior authorization or have step therapy.

Advantage MD Part B Prior Authorization Criteria

The prior authorization program is managed in collaboration with CVS Health–NovoLogix. Providers have access to the prior authorization system that allows for intake through a web-based portal, as well as access to real-time status updates.

Please utilize Availity to submit prior authorization requests or step therapy exceptions for Medicare Part B drugs.

How to request a medical benefit drug prior authorization:

  1. Submit electronic prior authorization requests through NovoLogix using the AMD Availity secure provider portal.
  2. If Availity is not able to be accessed, contact NovoLogix for assistance by calling: 800-932-7013.

Frequently Asked Questions

How do I determine if a specific treatment requires prior authorization or has step therapy?

All preferred and non-preferred Part B drugs are identified on the Advantage MD Part B Prior Authorization Drug list. Look for the drug on the list. If the drug is not listed, it does not require prior authorization. If it is listed as a Preferred Product, it does not require step therapy. If a non-preferred product is required, an organization determination must be submitted.

How do I determine the criteria for prior authorization?

Search the Advantage MD Part B Prior Authorization Criteria. list for the requested drug criteria.

How do I request a prior authorization for these services?

Submit the prior authorization request or the step therapy exception utilizing Advantage MD’s Availity Secure Provider Portal. If the request is approved, you will receive verification through our portal.

If you choose not to use Availity or have any questions regarding submission of prior authorization, you may call Novologix at 800-932-7013. They will fax you a drug specific questionnaire for you to complete and return via fax.

 

Over the Counter Product Coverage Benefit

Advantage MD will provide an over-the-counter (OTC) benefit for members in HMO, Primary PPO and D-SNP (HMO). A wide selection of drugs, supplies, and self-care products are provided without a prescription through the plan’s OTC benefit. Examples of OTC items include, but are not limited to:

  • First aid and medical supplies
  • Cough, cold and allergy
  • Pain relievers and sleep aids
  • Personal care
  • Antacids, digestive care and laxatives
  • Vitamins and minerals
  • Eye, ear, and dental care
  • Skin care
  • Mobility and safety

Members can select and order OTC products from the Advantage MD OTC Catalog. Advantage MD covers up to $200 every three months for D-SNP (HMO) members, and up to $60 every three months for HMO, up to $35 for HMO Tribute every three months, up to $50 for PPO Primary every three months, and up to $150 for HMO Select every three months. Any unused amount does not carry over to the next period. Available products and brands may change throughout the year and are subject to availability. Certain products are identified in the catalog as Dual-Purpose. Members are instructed to discuss these dual-purpose items with their prescriber since they are medicines and products that can be used for either a medical condition or for general health and well-being. Providers should discuss all OTC products with their patients but do not need to submit anything to the plan. The Advantage MD catalog for OTC items is available online at www.hopkinsmedicare.com. The OTC catalog contains a complete listing of all plan-covered OTC drugs, supplies, and self-care products and the price of each item. Members can have OTC products mailed to their homes once a quarter after placing an order online or via the OTC Program call center at 1-888-628-2770.