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Pharmacy & Formulary

pharmacist

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 Group (PPO)
  • Johns Hopkins Advantage MD (HMO)

Formularies
Cost Sharing Tiers
Prior Authorization, Quantity Limits, and Step Therapy
Exceptions
Appeal (Redetermination)
New Opiod Edits for 2019

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 Formulary
Advantage MD 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 Errata (list of formulary changes)
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 formulary search tool
HMO formulary search tool

Prior Authorization, Quantity Limits, and Step Therapy

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.  

Cost Sharing Tiers

Our 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 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.

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

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 90-day supply 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 patients: 877-293-5325 (option 2)
HMO patients: 877-293-4998 (option 2)

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 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

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

Appeal (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. 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 (option 2)
HMO patients: 877-293-4998 (option 2)

New Opioid Edits for 2019

The following edits are new for 2019 and 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 180 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.