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Pharmacies & Medications
Pharmacy & Formulary
USFHP Pharmacy Formulary
Prior Authorization, Quantity Limits, and Step Therapy
Drug Safety Information
Pharmacy Compounded Drugs
Johns Hopkins USFHP utilizes the TRICARE pharmacy formulary. The TRICARE formulary and pharmaceutical management policies are developed by the Department of Defense Pharmacy and Therapeutics Committee. The TRICARE formulary is a tiered, open formulary and includes generic drugs (Tier 1), preferred brand drugs (Tier 2), and non-preferred brand drugs (Tier 3). The Formulary is updated on a regular basis including Tier changes and utilization management requirements. Review the changes that will be made to the formulary.
The USFHP Pharmacy Program provides outpatient coverage to beneficiaries for medications that are approved for marketing by the U.S. Food and Drug Administration (FDA) and that generally require prescriptions. Other covered medications/products include:
- Compounded medications of which at least one ingredient is a legend drug
- Insulin syringes and needles
- Glucose test strips
Prescription medications used to treat conditions that are not currently covered by USFHP either by statute or regulation are likewise excluded from the pharmacy benefit.
Excluded medications include:
- Drugs prescribed for cosmetic purposes
- Fluoride preparations
- Food supplements
- Homeopathic and herbal preparations
- Over-the-counter products (except insulin, diabetic supplies, smoking cessation products, and select OTC products)
- Weight reduction products
USFHP members are responsible for a portion of the cost of their medications. The TRICARE formulary contains three copay tiers (cost share tiers) for USFHP members.
The cost share tiers are as follows:
Generic Drugs (Tier 1):
$11 – for up to 30 days' supply and $7 – for up to 90 days' supply of maintenance medications
Preferred Brand Drugs (Tier 2):
$28 – for up to 30 days' supply and $24 – for up to 90 days' supply of maintenance medications
Non-preferred Brand Drugs (Tier 3):
$53 – for up to 30 days' supply and $53 – for up to 90 days' supply of maintenance medications
Providers can view the cost share for a medication using the TRICARE formulary search tool. Providers can also search for lower cost alternative medications to a medication they are currently prescribing.
USFHP utilizes the TRICARE pharmacy formulary. The TRICARE formulary and pharmaceutical management policies are developed by the Department of Defense Pharmacy and Therapeutics Committee. The TRICARE formulary is a tiered, open formulary and includes generic drugs (Tier 1), preferred brand drugs (Tier 2), and non-preferred brand drugs (Tier 3). The Formulary is updated on a regular basis including Tier changes and utilization management requirements. Review the changes that will be made to the formulary.
DoD’s policy on generic drugs requires pharmacies to substitute generic medications for brand-name medications when a generic equivalent is available. Brand-name drugs with a generic equivalent may be dispensed only if the prescriber submits a prior authorization request and approval is granted by the JHHC USFHP Pharmacy Review Department. In those cases, USFHP members will pay the brand-name copayment. View the form to obtain prior authorization.
Generic drugs are chemically identical to their branded counterparts. They are made with the same active ingredients, and produce the same effects as their brand name equivalents. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand name drugs. Also, the FDA requires that all drugs, including generic drugs be safe and effective.
Although generic drugs are chemically identical to their branded counterparts, and are held to the same FDA standards for safety and performance as brand name drugs, they sell for 30-75 percent less. Additional information on generic drugs is available on the FDA website.
Some medications require prior authorization before they can be dispensed.
To determine if a drug requires prior authorization and view any applicable criteria, please search the TRICARE formulary tool.
To initiate a prior-authorization: Providers must download the Johns Hopkins USFHP Pharmacy Prior Authorization form, complete, and fax the form to the Johns Hopkins HealthCare Pharmacy Review department at 410-424-4037.
Please note: If another Health Plan or Tricare has previously approved a medication, USFHP will not have access to that information. If you have copy of the previous approval letter, please fax it along with the Prior Authorization Form to USFHP Pharmacy Review department.
Medical Necessity for Non-Formulary Medications (at Formulary Copayments):
Medical necessity criteria are established by the DoD Pharmacy & Therapeutics (P&T) Committee for each non-formulary medication. If the medical-necessity criteria are met, the beneficiary may receive the non-formulary medication at a lower co-payment. The provider can establish medical necessity by completing and submitting the Johns Hopkins Pharmacy Review department’s Prior-Authorization form.
The Department of Defense Pharmacy and Therapeutics Committee has established quantity limits for certain medications. Quantity Limits information may be found on the TRICARE formulary tool.
If a USFHP member's medical condition warrants use of quantities greater than listed quantity limit for their medication, Providers may submit a Prior Authorization request for use of the higher quantity. Providers must provide medical justification for use of the higher quantity. Download a copy of the Pharmacy Prior-Authorization form, complete and fax the Prior Authorization form to the Johns Hopkins Healthcare Pharmacy department at 410-424-4037.
Step therapy involves prescribing a safe, clinically effective, and cost-effective medication as the first step in treating a medical condition. The preferred medication is often a generic medication that offers the best overall value in terms of safety, effectiveness and cost. Non-preferred drugs are only prescribed if the preferred medication is ineffective or poorly tolerated.
Drugs subject to step therapy will be approved for first-time users only after they have tried one of the preferred agents on the DoD Uniform Formulary.
Note: A member who has filled a prescription for a step-therapy drug within 180 days prior to the implementation of step therapy, will not be affected by step-therapy requirements and will not be required to switch medications. Please note that the coverage terms of this prescription benefit are subject to change
To determine if a drug requires Step Therapy and view any applicable criteria, please search the TRICARE formulary tool.
If a provider determines that a step therapy requirement is not appropriate for a member, the Pharmacy Prior Authorization Form may be submitted for review. To initiate a prior-authorization, providers must complete and fax the Prior Authorization form to the Johns Hopkins Healthcare Pharmacy department at 410-424-4037.
The Johns Hopkins USFHP Plan allows retail prescription processing at any Walgreens pharmacy in the United States (including those Rite Aid pharmacies that converted to Walgreens pharmacies). Prescriptions may be filled for up to a 90 day supply at any network pharmacy. For members who prefer to utilize a mail order program for maintenance medications, the Walgreens Pharmacy at Remington provides this service for Maryland Residents only. Members who live outside of Maryland may obtain home delivery from AllianceRx Walgreens Prime Pharmacy in Arizona.
2700 Remington Ave.
Baltimore, MD 21211
AllianceRx Walgreens Prime Pharmacy
P.O. Box 29061
Phoenix, AZ 85038-9061
To view information on a drug, including how to take the medication, the possible side effects and drug interactions, members may log in and search Health Resources to see the drug’s side effects, precautions, drug interactions and how to use the medication.
To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications when rejected at the pharmacy may require prior authorization. The provider may complete the Compound Prior Authorization Form and fax to the Johns Hopkins Healthcare Pharmacy department at 410-424-4607 for review. The provider must provide clinical documentation to support the request and demonstrate that an FDA approved commercially-available product is not clinically appropriate for the member.
To request a prior authorization for applicable compounded drugs, use the Compounded Drug prior authorization form.
Specialty Medications are usually high-cost prescription medications used to treat complex chronic conditions. These drugs typically require special storage and handling, and may not be readily available at a local pharmacy. Specialty medications may also have side effects that require pharmacist and/or provider monitoring.
Specialty Medications - Pharmacy Benefit: Are self-administered and processed through the member’s pharmacy benefit. These medications are available at a network retail or specialty pharmacy and may require prior authorization. You may search for the specialty medications covered under pharmacy benefit on the Tricare Formulary. Use the Prior Authorization form to request prior authorization for self-administered specialty medications.
Specialty Medications – Medical Benefit: Are administered by a provider or under supervision of a provider and processed through the member’s medical benefit. Providers may supply these medications and bill the health plan for the medication and related administration using HCPCS Codes or J codes. For members 18 years and older, USFP requires prior authorization for Site of Care in order for certain medications to be administered in a Maryland hospital or regulated setting. Regulated setting is considered any health care setting whose rates are regulated by the Maryland Health Services Cost Review Commission (HSCRC).
Administration in non-hospital based settings such as a physician’s office, freestanding outpatient infusion facility or the member’s home do not require prior authorization. Please refer to the HCPCS J codes listed below for your reference.
The following medications require prior authorization or have site of care restriction:
|Medical Injection-Brand Name||HCPCS / J Code||Effective Date||Prior Authorization Form|
|Synagis®||90378||10/01/2006||Synagis Referral Form|
|Botox®||J0585||10/12/1998||Prior Authorization Form|
|Dysport®||J0586||10/12/1998||Prior Authorization Form|
|Xeomin®||J0587||10/12/1998||Prior Authorization Form|
|Myobloc®||J0588||10/12/1998||Prior Authorization Form|
|Actemra®*||J3262||1/1/2018||Providers seeking to perform outpatient infusion services in a Maryland hospital or regulated setting will need to submit a prior authorization request to JHHC via the HealthLINK@Hopkins portal or by fax at (410) 424-4603. Failure to obtain a prior authorization may result in a denial of payment.|
The prior authorization request should include all pertinent clinical information to support the medical necessity. If there are no medical reasons to have the infusion services in a Maryland hospital or regulated setting, the member should be referred to a freestanding outpatient infusion facility, physician office, or their own home by a qualified home care infusion provider.
*Note: The medication requires site of care authorization if administered at a regulated setting.
Use our Provider Directory for a list of participating infusion providers.
To request an outpatient infusion center addition to our participating network, please call the Provider Relations department at (888) 895-4998.
Providers may supply any vaccine for any age group under the medical benefit as long as a scheduled vaccine is in line with the Advisory Committee on Immunization Practices (ACIP) recommendations. Certain common vaccines such as Flu, Pneumonia and Shingles vaccines may be also be administered by Pharmacists at select Walgreens pharmacies.