2017 Prescription Drug Coverage

Please note: the information on this page does not apply to Advantage MD Group.

Prescription Drug Overview

We know prescription drug coverage is very important to you. That’s why Johns Hopkins Advantage MD (PPO) offers a Part D prescription benefit with both of our plan options. Search through our latest listing of prescription drugs below or view our full list of drugs by searching through our pharmacy formulary or using our formulary search tool.

Find a pharmacy in your area using our pharmacy locator, or skip the trip and use our convenient mail order pharmacy program.

If you need help finding a network pharmacy, please call us at 1-877-293-5325 and select Option 2 (TTY:711), or if you would like a pharmacy directory mailed to you, please select Option 3. We are available for assistance 24 hours a day, seven days a week.

Note: The formulary and pharmacy network may change at any time. You will receive notice when necessary.

List of Drugs (Prescription Drug Formulary)

The Johns Hopkins Advantage MD Comprehensive Formulary is a complete list of Medicare-approved, prescription brand-name and generic medications we cover.

Download the Advantage MD Medicare Part D Comprehensive Formulary.

You may also search our formulary for a drug using the formulary search tool. The results will let you know whether a drug is covered and if there are formulary alternatives such as lower-cost generic or brand drugs. The searchable formulary may not include all covered drugs. For a complete list, refer to the most recent comprehensive formulary document for verification of formulary status.

We include formulary alternatives in the formulary search tool to help you and your prescribing doctor determine the proper course of action to take when one of your medications is not covered by your plan. This is not a complete list of all formulary alternatives covered by your Part D plan. The drugs listed are for comparison purposes and may differ in effectiveness, dosing, side effects and/or drug interaction profiles. Always seek the advice of your doctor regarding your prescription medications.

The formulary alternatives will assist you in determining whether to request an exception or to simply have your physician write a new prescription for a formulary alternative. To help your doctor decide whether to prescribe a formulary alternative, please print your Plan’s comprehensive formulary and take it with you when you visit your doctor. Remember, by switching to an alternative generic or brand-name drug included on our formulary, you can avoid paying the full cost for a non-formulary drug.

Formulary Search Tool

 

Notice of Part D Formulary Updates

Our formulary is updated monthly or whenever formulary changes occur. We may remove drugs from the formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, and/or move a drug to a higher cost-sharing tier during the plan year. If the change affects a drug you take, we will notify you in writing at least 60 days before the change is effective. However, if the U.S. Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or if the drug’s manufacturer removes a drug from the market, we will immediately remove the drug from the formulary and notify all affected members as soon as possible.

See the changes that will be made to the formulary.

To find out if a drug is covered, simply search the Comprehensive Formulary. For questions regarding drugs we cover, contact us toll-free at 1-877-293-5325 and select Option 2 (TTY:711), or to obtain a print version of the comprehensive formulary, select Option 3. We are available for assistance 24 hours a day, seven days a week.

Find a Pharmacy Near You

Pharmacy Locator Tool

Use the pharmacy locator tool to search for a network pharmacy in your area. A network pharmacy is a pharmacy that we have made arrangements with to provide prescription drugs to our members. Once you go to a network pharmacy, you are not required to continue going to the same network pharmacy to fill your prescriptions. You can go to any of our network pharmacies or skip the trip and use our convenient mail order pharmacy program.

We will fill prescriptions at out-of-network pharmacies under certain circumstances as described in the “Out-of-Network Pharmacy Coverage ” section below. Through CVS Caremark, we currently have over 65,000 pharmacies in our nationwide pharmacy network. The pharmacy network may change at any time. You will receive notice when necessary. If you need help finding a network pharmacy, please call us at 1-877-293-5325  and select Option 2 (TTY:711), 24 hours a day, seven days a week. If you want a pharmacy directory mailed to you, select Option 3.

Out-of-Network Pharmacy Coverage

Mail Order Pharmacy Program

For certain kinds of drugs, you have the option to sign up for the plan’s network mail order services and get prescription drugs shipped to your home. Generally, the drugs provided through the mail order service are drugs that you take on a regular basis for a chronic or long-term medical condition.

Our plan’s mail order service allows you to conveniently order up to a 90-day supply of medication on Tier 1 through Tier 4 at a reduced copay. This means you can get a 90-day supply for only 2.5 times the retail copay—saving you the equivalent of 2 retail copays per year. Drugs in Tier 5 are only available as a 30-day supply. Usually a mail-ordered prescription will get to you in no more than ten days. If the mail order pharmacy expects a delay of more than ten days, they will contact you and help you decide whether to wait for the medication, cancel the mail order, or fill the prescription at a local pharmacy. If your order does not arrive within ten days, you may also call us at 1-877-293-5325 and select Option 2 (TTY:711), 24 hours a day, seven days a week.

For refills of your mail order drugs, you have the option to sign up for an automatic refill program called ReadyFill at Mail®. Under this program, the mail order pharmacy will start to process your next refill automatically when their records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use the auto refill program, please contact the mail order pharmacy 15 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.

For more information, please see Chapter 5 of your Evidence of Coverage (EOC).

Download the Mail Order Pharmacy Form

Part D Coverage Determinations, Exceptions, Appeals and Grievances

Transition Policy

Vaccine Coverage

Getting the vaccinations you need is important for your best health. Getting vaccines administered at the right location is important for your best coverage. Learn about your vaccine coverage, administration options, and what you should expect to pay on our Vaccine Administration Policy page.

Medicare Part B vs. Part D Drugs

Johns Hopkins Advantage MD covers both Medicare Part B and Part D medications. To see examples of Part B medications and Part D medications and where to obtain the medication, view the Medicare Part B vs. Part D chart.

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. If you have any questions, call Customer Service at 1-877-293-5325, option 3 (TTY: 711).

If you previously purchased diabetes testing supplies from a pharmacy without using your Advantage MD insurance, you may fill out a Part B claim form to go through the reimbursement process.

Low Income Subsidy Information

Low income subsidy (LIS), also known as Extra Help, is a program that helps individuals who have a limited income pay for their Medicare prescription drug costs. If you get extra help from Medicare to help pay for your prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan. The LIS Premium Summary Chart will show you what you’ll pay each month depending on the plan you have and the level of extra help you get.

Download the LIS Premium Summary Chart