Rx determinations and appeals

As a member, you have the right to ask us to make an exception to our plan formulary. Examples of formulary exception requests include asking us to:

• Cover your Part D drug even if it is not included on our formulary. This is referred to as a formulary exception request.
• Provide your drug at a lower copayment if there are drugs for your condition at a lower copayment level. For example, if your drug is included in Tier 2, and there are drugs to treat your condition in Tier 1, you can ask us to cover it at the Tier 1 cost-sharing amount instead. This is referred to as a tiering exception request.

Note: If we grant your request to cover a drug that is not on our formulary, you may not also request a higher level of coverage for the same drug. Also, you may not ask us to provide a higher level of coverage for any Tier 5 (Specialty Tier) drugs.

The best way to request a drug formulary exception, or a tiering exception, is with the help of your prescribing doctor. He or she must provide a written statement that explains the medical reasons for requesting an exception. Your doctor can submit a statement to us using a coverage determination form; however, no specific form is required.

For certain prescription drugs, additional coverage or limit requirements may be in place to help our members use these drugs in a safe way, while also helping to control costs for everyone. We, therefore, require you to get a prior authorization (prior approval) before certain drugs will be covered under the plan.

• 2025 PPO and Plus (PPO) Prior Authorization Criteria
• 2025 HMO Prior Authorization Criteria
• 2025 D-SNP (HMO) Prior Authorization Criteria

• 2026 PPO and Plus (PPO) Prior Authorization Criteria
• 2026 HMO Prior Authorization Criteria
• 2026 D-SNP (HMO) Prior Authorization Criteria

To request a prior authorization, you and/or your doctor may complete and submit a Coverage Determination form.

Your prescribing doctor will need to tell us the medical reason why your Johns Hopkins Advantage MD plan should authorize coverage of your prescription drug. Without the necessary information on the prior authorization form, we may not approve coverage of the drug.

Submit online:

Paper request:

2025

• PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

2026

• PPO Paper Prescription Drug Coverage Determination Request
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

Mail to:

Johns Hopkins Advantage MD
c/o CVS/Caremark Part D Services
Coverage Determination and Appeals Department
PO BOX 52000 MC 109
Phoenix, AZ 85072-2000

Submit online:

Paper request:

2025

• PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

2026

• PPO Paper Prescription Drug Coverage Determination Request
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

By phone:

You can file a request by phone or call to ask for help submitting your request 24 hours a day, seven days a week.

PPO members: call 877-293-5325 (TTY: 711).

HMO members: call 877-293-4998 (TTY: 711.

Fax:

To fax your written request, use our toll-free fax number: 1-855-633-7673

Mail:

To submit a standard request in writing, mail to:

Johns Hopkins Advantage MD

c/o CVS/Caremark Part D Services

Coverage Determination and Appeals Department

PO BOX 52000 MC 109

Phoenix, AZ 85072-2000

If we approve your exception request, our approval is typically valid until the end of the plan year as long as your prescribing doctor continues to prescribe the Part D drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you may ask for a review of our decision (called a redetermination) by submitting an appeal. You must request this appeal within 60 calendar days from the date of our first decision.

We accept standard and expedited requests by telephone and in writing.

Submit online:

• Online Medicare Prescription Drug Coverage Redetermination Request

Paper request:

2025

• PPO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
• HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish

2026

• PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

By phone:

You can file a request by phone or call to ask for help submitting your request 24 hours a day, seven days a week.

PPO members: call 877-293-5325 (TTY: 711).

HMO members: call 877-293-4998 (TTY: 711).

Fax:

To fax your written request, use our toll-free fax number: 1-855-633-7673

Mail:

To submit a standard request in writing, mail to:

Johns Hopkins Advantage MD

c/o CVS/Caremark Part D Services

Coverage Determination and Appeals Department

PO BOX 52000 MC 109

Phoenix, AZ 85072-2000

For standard exception requests, we will let you know of our decision within 72 hours after the exception request form is submitted to us with your doctor’s supporting statement.

You also have the option to request an expedited exception request if your doctor believes your health could be seriously harmed by waiting up to 72 hours for a decision. If the coverage determination form submitted to us with your doctor’s supporting statement is considered urgent, and we agree, we will let you know of our decision within 24 hours of your request.

To find out if these restrictions apply to a drug you take:

Search for the drug using the online formulary search tool or review your plan’s formulary.

2025

• PPO and Plus (PPO) Formulary Search Tool
• Primary (PPO) Formulary Search Tool
• HMO Formulary Search Tool
• D-SNP (HMO) Formulary Search Tool
• Select (HMO) Formulary Search Tool
• PPO and Plus (PPO) Formulary Formulary
• HMO Formulary
• Primary (PPO) Formulary
• D-SNP (HMO) Formulary – English | Spanish
• Select (HMO) Formulary

2026

• PPO and Plus (PPO) Formulary Search Tool
• Primary (PPO) Formulary Search Tool
• HMO Formulary Search Tool
• D-SNP (HMO) Formulary Search Tool
• Select (HMO) Formulary Search Tool
• PPO and Plus (PPO) Formulary Formulary
• HMO Formulary
• Primary (PPO) Formulary
• D-SNP (HMO) Formulary – English | Spanish
• Select (HMO) Formulary

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

• PA – Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
• QL – Drug has Quantity limit.  For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for rosuvastatin.
• ST Step Therapy. – In some cases, our plan requires you to first try certain drugs to treat your medical condition, before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
• NM – Not available at mail order pharmacies.
• 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.
• EX – This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
• V/I – This drug’s Tier Copay may not apply to you. Our plan covers most Part D vaccines at no cost to you. Our plan covered insulin is no more than $35 for a one-month supply. Call Customer Service for your estimated cost.
• * – Non-extended day supply. Not available for an extended (long-term) supply

You can also call us toll-free, 24 hours a day, seven days a week.

PPO members: call 877-293-5325 (TTY: 711).

HMO members: call 877-293-4998 (TTY: 711).

Certain covered drugs require a quantity limit restriction. That means we will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is medically necessary to exceed the set limit, he or she must get prior approval before the higher quantity can be covered. Quantity limits are generally used as a safety precaution to prevent certain prescription drugs from being used excessively. To request a quantity limit exception, you and/or your doctor may complete and submit a coverage determination form. You may download the form and send it back to us or submit your request online through our secure website.

• 2025 PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• 2025 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
• 2026 PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• 2026 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish

A step therapy requirement means you must first try one drug to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat your medical condition, and both are covered drugs, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. To request a step therapy exception, you and/or your doctor may complete and submit a coverage determination form. You may download the form and send it back to us or submit your request online through our secure website.

2025

• PPO and Plus (PPO) Step Therapy Criteria
• HMO Step Therapy Criteria
• D-SNP (HMO) Step Therapy Criteria
• PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
• Online Medicare Prescription Drug Coverage Determination

2026

• PPO and Plus (PPO) Step Therapy Criteria
• HMO Step Therapy Criteria
• D-SNP (HMO) Step Therapy Criteria
• PPO Paper Prescription Drug Coverage Determination Request
• HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
• Online Medicare Prescription Drug Coverage Determination

You may name someone to act for you as a representative. This person can be a relative, friend, lawyer, advocate, doctor, or someone else. You may already have someone authorized by the Court or in accordance with State law to act for you. To authorize someone to act as your representative, you and that person must sign and date a statement that gives the person legal permission to do so.

To assign an appointment of representative, download, print, and complete the form and mail to either of the following locations.

• Appointment of Representative form

For coverage determination or appeal-related issues, mail the form to:

Johns Hopkins Advantage MD

c/o CVS/Caremark Part D Services

Coverage Determination & Appeals Dept.

PO BOX 52000 MC 109

Phoenix, AZ  85072-2000

For grievance-related issues, mail the form to:

Johns Hopkins Advantage MD

c/o CVS/Caremark Part D Services

Medicare Part D Grievances Department

P.O. Box 30016

Pittsburgh, PA 15222-0330

For additional information, you may call us 24 hours a day, seven days a week.

PPO members: call 877-293-5325 (TTY: 711).

HMO members: call 877-293-4998 (TTY: 711).

You should share a copy of the decision with your doctor so you and your doctor can discuss next steps. If we make a coverage decision and you are not satisfied with this decision, you or your provider can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. The directions on how to file an appeal are in your notification letter or in Chapter 9 of your Evidence of Coverage.

Your provider is responsible for submitting the prior authorization or step therapy exception request. Your provider is aware of how to submit this request. Once Advantage MD reviews the request, you will be notified of the decision via phone and mail. Please contact your provider to determine next steps.

All preferred and non-preferred Part B drugs are identified on the Advantage MD Part B Prior Authorization List. Look for your drug on the list. If your drug is not listed, it does not require prior authorization. If it is listed as a Preferred Product, it does not require step therapy.

Some medications require prior authorization from your plan before they can be dispensed by your in-network pharmacy. This helps us ensure that your prescriptions are medically necessary. To determine if a medication requires prior authorization, refer to the Pharmacy Formulary specific to your Advantage MD plan. Your physician can request these medications by submitting a prior authorization request. Information about covered medications, medication prior authorization requirements and pharmacy plan benefits are available here.

Part D: Standalone Prescription Drug Plans

Helps cover some of your prescription drug costs. These plans are offered by private insurance companies who are contracted by Medicare — when you have Part D, you pay a second monthly premium in addition to Medicare. To enroll, you must be enrolled in Original Medicare and live within the plan’s service area. A late enrollment penalty may apply if you choose to enroll after your Initial Enrollment Period.

There are three drug stages to Part D coverage: Deductible stage, Initial Coverage stage and Catastrophic Coverage stage.

The Deductible Stage is the first payment stage for your drug coverage. The deductible doesn’t apply to covered insulin products and most adult Part D vaccines, including shingles, tetanus, and travel vaccines. You will pay a yearly deductible on Tier 3, Tier 4 and Tier 5 drugs. You must pay the full cost of your Tier 3, Tier 4 and Tier 5 drugs until you reach the plan’s deductible amount. For all other drugs, you will not have to pay any deductible. The full cost is usually lower than the normal full price of the drug since our plan has negotiated lower costs for most drugs at network pharmacies. Once you have paid your deductible for your Tier 3, Tier 4 and Tier 5 drugs, you leave the Deductible stage and move on to the Initial Coverage Stage.

During the Initial Coverage stage, Advantage MD shares the cost of your covered prescription drugs, and you pay your share (your copay or co-insurance amount). You pay a copay for drugs in Tiers 1 and 2 and a co-insurance for drugs in Tiers 3, 4 and 5. You are in the Initial Coverage stage until your out-out-pocket costs total $2,000 in 2025 or $2,100 in 2026 — this is the maximum you will spend on covered drugs. You then move on to the Catastrophic Coverage stage.

After you reach the out-of-pocket maximum of $2,000 in 2025 or $2,100 in 2026, you enter the Catastrophic Coverage stage. Once you are in the Catastrophic Coverage stage, you will stay in this payment stage until the end of the calendar year. During this payment stage, you pay nothing for your covered Part D drugs and for excluded drugs* that are covered under our enhanced benefit.

*Advantage MD D-SNP (HMO) does not have excluded drug coverage.