Prescription Drug Coverage
Plan Specific Resources
Advantage MD PPOCollapseExpand
Advantage MD HMOCollapseExpand
Prescription Drug Formulary (List of Covered Drugs)
We know prescription drug coverage is very important to you. That’s why Johns Hopkins Advantage MD offers a Part D prescription benefit with our plan options.
The Johns Hopkins Advantage MD comprehensive formulary is a complete list of Medicare-approved, prescription brand-name and generic medications we cover.
Download the comprehensive formulary or use our formulary search tool to find drugs that are covered by Advantage MD:
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. To help your doctor decide whether to prescribe a formulary alternative, please download and 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.
Note: 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.
Notice of Part D Formulary Updates
Our formulary is updated monthly and as 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. The list of changes that have been made to the formulary is called the errata.
We may immediately remove a brand name drug on our Drug List if, at the same time, we replace it with a new generic drug on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are taking the brand name drug at the time we make the change, we will provide you with information about the specific change(s) we made. This will also include information on the steps you may take to request an exception to cover the brand name drug. You may not get this notice before we make the change.
For other changes to drugs on the Drug List, if the change affects a drug you take, we will notify you in writing at least 30 days before the change is effective or we will give you a 30-day refill on the drug you are taking at a network pharmacy.
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.
To view the latest changes that have been made to the formulary, you can download and refer to the errata sheet:
For questions about drugs covered in the PPO formulary, call us toll-free at 877-293-5325 (TTY: 711) and select option 2.
For questions about drugs covered in the HMO and HMO D-SNP formularies, call us toll-free at 877-293-4998 (TTY: 711) and select option 2.
You may obtain a print version of your formulary by selecting option 3. We are available for assistance 24 hours a day, seven days a week.
Specialty Medications – Medical Benefit
Some medications covered by Johns Hopkins Advantage MD require prior authorization (or pre-authorization) and/or step therapy.
- Prior Authorization means that Advantage MD must first approve the medication before your provider can prescribe or administer it. Advantage MD verifies the medical necessity of the medication using independent, objective medical criteria.
- Step therapy means that preferred products must be used before non-preferred agents. Your provider may request an exception to the step therapy for specific circumstances that warrant a need for a non-preferred product.
Your provider requests this approval and exception — it is their responsibility.
Certain medical injectable drugs also require prior authorization or step therapy. Medical injectable drugs are medications that you do not self-administer. These are drugs that usually are injected or infused while you are getting services from a physician, hospital outpatient facility, or ambulatory surgical center. These drugs are covered by Advantage MD under the medical benefit (Part B).
Advantage MD is committed to delivering cost-effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary, according to current standards of practice.
FREQUENTLY ASKED QUESTIONS:
How do I determine if my treatment requires prior authorization or step therapy?CollapseExpand
All Part B drugs requiring prior authorization are identified in 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.
All preferred and non-preferred Part B drugs are identified on the Biosimilars-first Medical Preferred Drug List. Look for your drug on the list. If it is listed as a Preferred Product, it does not require step therapy.
What do I do if my treatment requires prior authorization or step therapy?CollapseExpand
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.
What if my authorization is not approved?CollapseExpand
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.
Use our pharmacy locator tool to find a pharmacy in your area where you can get your prescriptions, or skip the trip and have your prescriptions mailed to your home through our mail order pharmacy program:
If you need help finding a PPO network pharmacy, please call us toll-free at 877-293-5325 and select option 2 (TTY:711).
If you need help finding an HMO network pharmacy, please call us toll-free at 877-293-4998 and select option 2 (TTY:711).
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.
Access Your Personalized Pharmacy Information
You have secure access to all of your personal prescription benefit information so you can easily manage your health online where and when you need to. Register your account at caremark.com for time and savings opportunities, and discover these benefits:
- Review your prescription history
- Check drug cost and coverage
- Review your prescription savings guide for savings opportunities
- Track and print your prescription drug spending
- Order your long-term medications through mail service
- View your mail service prescription order status
3 easy ways to register:
- Online. Enter your information to register on caremark.com.
- On your phone or tablet. Download the CVS/caremark mobile app from the App Store or Google play.
- Call us. PPO members, call 877-293-5325 (TTY: 711) and select option 2; HMO members, call 877-293-4998 (TTY: 711) and select option 2. Our Customer Service will get you started with a personalized registration email or text.
For New MembersCollapseExpand
If you were taking a non-formulary drug, or a drug with a Step Therapy or Prior Authorization restriction before joining our plan, our transition process will allow the pharmacist who refills your prescription to provide you with a temporary 30-day supply of the drug within the first 90 days of your membership in a Johns Hopkins Advantage MD plan. A thirty (30) day supply is the maximum transition amount, and could be less if your prescription is written for fewer days. Your prescription must be filled at a network pharmacy, and your cost is determined by your plan’s appropriate tier copay.
A transition supply gives you time to talk to your doctor about pursuing other options available to you within our formulary. Unless you obtain an authorization or exception, we cannot continue to pay for these medications under the transition policy, even if you have been a member for less than 90 days following your 30-day transition supply.
For Current MembersCollapseExpand
As a renewing or continuing member, you will receive your Annual Notice of Change (ANOC) by September 30. After reviewing your ANOC, if you notice that a covered prescription drug you currently take will either not be covered in the future year’s formulary or its cost sharing or coverage has changed for the current plan year, you should discuss your situation with your doctor to either find an appropriate alternative prescription drug that is covered by the formulary, or request an authorization or exception before the new plan year begins. If your request is approved, we will authorize coverage before the new plan year.
If you are affected by formulary changes from one contract year to the next, you may be eligible to receive a temporary 30-day supply of your prescription drug within the first 90 days of the new plan year while you work with your doctor to either obtain a covered alternative prescription drug or request a formulary exception. A thirty (30) day supply is the maximum transition amount, and could be less if your prescription is written for fewer days. Your prescription must be filled at a network pharmacy, and your cost is determined by your plan’s appropriate tier copay.
For Long-Term Care ResidentsCollapseExpand
If you were taking a non-formulary drug or a prescription drug with a Step Therapy or a Prior Authorization restriction before you joined Johns Hopkins Advantage MD and you reside in a Long Term Care facility, the pharmacist who refills your prescription will be able to provide you with up to a 31-day supply of your prescription drug unless you have a prescription written for fewer days during the first 90 days of your membership in our plan. Your prescription must be filled at a network pharmacy, and your cost is determined by your plan’s tier cost sharing amount (copay or coinsurance). This gives you time to talk to your doctor about pursuing other options available to you within our formulary.
Level of Care ChangeCollapseExpand
If you are outside of the transition period and are experiencing circumstances that involve a level of care change (moving from home to a long-term care facility, or from a long-term care facility to home), the pharmacist who refills your prescription will be able to provide you up to a 31-day supply (unless you have a prescription written for fewer days) of your medications. Your prescription must be filled at a network pharmacy, and your cost is determined by your plan’s tier cost sharing amount (copay or coinsurance). This gives you time to talk to your doctor about pursuing other options available to you within our formulary.
Transition Supply LetterCollapseExpand
If you receive a transition supply from a pharmacy, you will receive a letter from us notifying you that you have received a temporary supply of your prescription drug. When you receive a transition fill letter, you should speak to the plan and/or your physician regarding whether you should change the drug you are currently taking, or request an authorization or exception from the plan to continue coverage of this drug.
How do I obtain additional information regarding Transition Supply?CollapseExpand
Please refer to your EOC for more detailed information on Johns Hopkins Advantage MD Medicare Transition Process. For questions and help requesting a formulary exception, please call us.
PPO members: 877-293-5325 (TTY: 711) and select option 2.
HMO members: 877-293-4998 (TTY: 711) and select option 2.
We are available 24 hours a day, seven days a week.
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 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.
If you receive extra help, download and refer to the LIS Premium Summary Chart to show you what you’ll pay each month depending on the plan you have and the level of extra help you get:
Best available evidence
Johns Hopkins Advantage MD relies on the Centers for Medicare & Medicaid Services (CMS) to determine plan member eligibility for extra help/Low Income Subsidy (LIS). Sometimes, CMS systems may not have the most up-to-date information. If you believe that you are not paying the correct monthly premium or costs for your drugs and are eligible for extra help/LIS, you can submit the Best Available Evidence (BAE) to Advantage MD. Once we receive your BAE, we will ask CMS to update your LIS status in its systems.
Acceptable forms of Best Available Evidence include:
- A copy of your Medicaid card, which includes your name and the eligibility date.
- A copy of a letter from the state or the Social Security Administration (SSA) showing your Medicare LIS status.
- A copy of a state document that confirms your active Medicaid status.
- A screen print from the State’s Medicaid systems showing your Medicaid status.
- Evidence at point-of-sale of recent Medicaid billing and payment in the pharmacy’s patient profile, backed up by one of the above indicators post point-of-sale.
You must mail one of the accepted forms of BAE to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
If you have questions about BAE or need help getting documented proof, please call Member Services.
PPO members: 877-293-5325 (TTY: 711)
HMO members: 877-293-4998 (TTY: 711)
For more information, refer to Chapter 2 in your Evidence of Coverage. The full BAE policy is available at CMS.gov.