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Pharmacy Drug Policies

  • You will have access to Johns Hopkins HealthCare LLC (JHHC) Medical Policies and Guidelines for the purpose of gaining information.
    • Johns Hopkins HealthCare LLC (JHHC) Medical Policies are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any policy changes related to their coverage or condition with their treating provider.
    • While the Medical Policies are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Medical Policies express Johns Hopkins HealthCare's general determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
    • While Medical Policies define Johns Hopkins HealthCare's general clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis In the event that a member disagrees with a coverage determination, Johns Hopkins HealthCare LLC provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and non-ERISA (e.g., government, school boards, church) plans. For information on Johns Hopkins HealthCare's External Review Program contact Care Management.
    • The five character codes included in the Johns Hopkins HealthCare LLC Medical Policies are obtained from Current Procedural Terminology (CPT®), by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
    • The responsibility for the content of Johns Hopkins HealthCare LLC Medical Policies is with Johns Hopkins HealthCare LLC and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Johns Hopkins HealthCare LLC Medical Policies. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Johns Hopkins HealthCare LLC Medical Policies should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
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