Advantage MD utilizes multiple formularies. The member’s plan determines which formulary applies:

• Advantage MD PPO/Plus PPO Formulary
• Advantage MD Primary (PPO)
• Advantage MD HMO Formulary
• Advantage MD D-SNP (HMO) Formulary
• Advantage MD Select Virginia (HMO) Formulary

 

The Advantage MD formularies are subject to change at any time upon Medicare approval. Formulary changes will be reflected in the updated formularies and in the formulary changes lists below.

• PPO/Plus PPO Errata (list of formulary changes)
• HMO/Primary PPO Errata (list of formulary changes)
• D-SNP (HMO) Errata (list of formulary changes)

You may also search for a specific drug in one of our formularies using our formulary search tools. The searchable formulary may not include all covered drugs. Please see the most recent comprehensive formulary document for verification of formulary status.

• PPO/Plus PPO formulary search tool
• PPO Primary formulary search tool
• HMO formulary search tool
• D-SNP (HMO) formulary search tool
• Select Virginia (HMO) formulary search tool

 

Advantage MD plans, except D-SNP, allows 100-day supplies on Tier 1 maintenance medications for the same cost as a 90-day supply.  Please consider prescribing generic blood pressure, cholesterol, and diabetes medications as 100-day supplies to help your patients save money and improve their adherence.

The search results and formulary drug list will indicate if any prior authorizations, quantity limits, or step therapy requirements apply.

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

• PA - Prior authorization required
• QL - Drug has a quantity limit
• ST - Step therapy required
• 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.
• * Not available as extended days' supply (greater than 30 days' supply)
• EX - This prescription drug is not normally covered in a Medicare Prescription Drug Plan but is covered by Advantage MD
• I – This drug's Tier Copay may not apply to you. Our plan covered insulin is no more than $35 for a one-month supply. Call Customer Service for your estimated cost.

Preferred Generic Drugs have the lowest out-of-pocket cost for members and are placed on Tier 1. Generic drugs are listed in italic type in the formulary.

Generic Drugs have a low out-of-pocket cost for members. Some low-cost preferred brands are also included.

Preferred Brand Drugs have an intermediate out-of-pocket cost for members. Some non-preferred generic drugs are also included.

Non-Preferred Drugs have a higher out-of-pocket cost for members.

Specialty Tier Drugs have the highest out-of-pocket cost for members.

Certain medications require prior authorization before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. Coverage of these drugs are subject to specific criteria approved by Medicare. Established criteria are based on medical literature, physician expert opinion, and Food and Drug Administration (FDA) approved labeling information.

• PPO Prior Authorization Criteria
• HMO/Primary PPO Prior Authorization Criteria
• D-SNP (HMO) Prior Authorization Criteria

Certain medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the FDA, and current medical literature, and are approved by Medicare. To find the quantity limit for certain medications, please refer to the appropriate formulary/formulary search tool.

Certain medications are required to satisfy specific step therapy criteria. Step therapy criteria simply means that for certain drug products, members must first have tried one or more prerequisite medications to treat their condition before other medications are covered through their benefit. To find if a drug requires a Step Therapy and criteria, please refer to the appropriate formulary/formulary search tool.

• PPO Step Therapy Criteria
• HMO Step Therapy Criteria
• D-SNP (HMO) Step Therapy Criteria

 

• Formulary Exceptions can be requested when a medical condition warrants use of certain medications not on the formulary. Clinical documentation should be provided to support all requests.
• Quantity Exceptions can be requested when a medical condition warrants use of quantities greater than listed quantities for each drug. Clinical documentation should be provided to support all requests.
• Step Therapy Exceptions can be requested when there is contraindication to the prerequisite medication or there is documented trial and failure of prerequisite medication.
• Tier Exceptions can be requested to provide the drug at a lower cost-sharing tier when the drugs at a lower copayment level have been tried and failed or are contraindicated. Tier 5 (Specialty Tier) medications are exempt from tier exception. Clinical documentation should be provided to support all requests.

• Submit your request electronically, by using the online Request for Medicare Prescription Drug Coverage Determination form
• Download the applicable Request for Medicare Prescription Drug Coverage Determination form below, complete, and send with clinical supporting documentation.
  • PPO Prescription Drug Coverage Determination Request
  • HMO and D-SNP Prescription Drug Coverage Determination Request
  • PPO Step Therapy Exception Request
  • HMO and D-SNP Step Therapy Exception Request
  • PPO Quantity Limit Exception Request
  • HMO and D-SNP Quantity Limit Exception Request
  • PPO Formulary Exception Request
  • HMO and D-SNP Formulary Exception Request
  • PPO Tier Exception Request
  • HMO and D-SNP Tier Exception Request
• Fax to: 1-855-633-7673
• Mail to:
  Johns Hopkins Advantage MD
  c/o CVS Caremark Part D Services
  Coverage Determination & Appeals Dept.
  P.O. Box 52000 MC 109
  Phoenix, AZ 85072-2000
• To file a request by phone, call Customer Service toll-free, 24 hours a day, seven days a week.
  PPO patients: 877-293-5325
  HMO and D-SNP patients: 877-293-4998

If a request is denied, an appeal or a redetermination may be filed within 60 calendar days from the date of the first decision.

• Submit electronically by using the Medicare Coverage Redetermination form
• Download and complete the Request for Redetermination of Medicare Prescription Drug Denial form and send with clinical supporting documentation:
  • PPO Prescription Drug Coverage Redetermination Request
  • HMO Prescription Drug Coverage Redetermination Request
• Mail to:
  Johns Hopkins Advantage MD
  c/o CVS Caremark Part D Services
  Coverage Determination & Appeals Dept.
  P.O. Box 52000 MC 109
  Phoenix, AZ 85072-2000
• Fax to: 1-855-633-7673
• Expedited appeal requests can be made by phone, 24 hours a day, seven days a week.

  PPO patients: 877-293-5325
  HMO and D-SNP patients: 877-293-4998

• In the CMS 2019 Call Letter, all Part D sponsors are required to implement a safety edit reject to limit initial opioid prescription fills for the treatment of acute pain to no more than a seven days supply. Therefore, if an opioid naïve patient attempts to fill more than a seven days supply of an opioid, the prescription will reject at the pharmacy.
• Exemptions to this are patients with a cancer diagnosis, residence in a Long-Term Care facility, Hospice, Palliative Care, and patients who are not opioid naïve.
• Pharmacies may request opioid prescribers to submit a Coverage Determination for prescriptions for opioid naïve members when days supply exceeds seven days.

• This rejection will occur if the cMME dose is greater than 90mg and the Part D Enrollee has received opioid prescriptions from four or more prescribers in the previous 108 days.
• This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation or request prescribers to submit a Coverage Determination.

• This rejection will occur when prescribed drugs have the same therapeutic effects as medication(s) the Part D Enrollee is currently taking (i.e. member is filling two or more long-acting opioids).
• This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation.

• This rejection will occur when interacting drug combinations are identified (i.e. member is filling opioids and benzodiazepines).
• This rejection may be overridden by the pharmacist but they may contact the prescriber for confirmation.

All preferred and non-preferred Part B drugs are identified on the Advantage MD Part B Prior Authorization Drug list. Look for the drug on the list. If the drug is not listed, it does not require prior authorization. If it is listed as a Preferred Product, it does not require step therapy. If a non-preferred product is required, an organization determination must be submitted.

Search the Advantage MD Part B Prior Authorization Criteria list for the requested drug criteria.

Submit the prior authorization request or the step therapy exception utilizing Advantage MD’s Availity Secure Provider Portal. If the request is approved, you will receive verification through our portal.

If you choose not to use Availity or have any questions regarding submission of prior authorization, you may call Novologix at 800-932-7013. They will fax you a drug specific questionnaire for you to complete and return via fax.

The Medicare Prescription Payment Plan (MPPP) is a payment option that may help patients manage their prescription drug costs. Under the MPPP, members can pay out-of-pocket prescription drug costs in the form of monthly payments over the course of the plan year instead of all at once to the pharmacy. Members would pay $0 to the pharmacy for covered Part D drugs, and Advantage MD would then bill members monthly for any cost sharing they incur.

Whether or not the payment plan is right for a member depends on their situation.

Members may benefit from the payment plan if they:

• Have high out-of-pocket drug costs early in the year
• Are prescribed a higher cost drug during the year and want to spread out the cost of their next refill
• Expect to exceed their annual out-of-pocket maximum ($2000)

Members may not benefit from the payment plan if they:

• Have low yearly drug costs
• Have the same drug costs each month
• Do not want to change how they pay for their drugs
• Get or are eligible for Extra Help from Medicare or a Medicare Savings Program
• Get help paying for their drugs from another organization or program
• Do not expect to exceed their annual out-of-pocket maximum ($2000)

This payment option might help them manage their monthly expenses, but it does not save them money or lower their drug costs.

There are three ways members can sign up for the MPPP through Advantage MD:

1. Complete the form online at caremark.com/mppp. Members can create/log in to the account and submit the form electronically.
2. Enroll over the phone.
3. Members can print out the form on our website at hopkinsmedicare.com/mppp and mail it to us at:

Johns Hopkins Advantage MD
Medicare Prescription Payment Plan
P.O. Box 7
Pittsburgh, PA 15230

Members can sign up for this payment option at any time during the plan year. Requests to enroll in the payment plan before the plan year begins will be processed in 10 calendar days after receipt. Requests to enroll during the plan year will be processed within 24 hours of receipt.

The payment plan will not reduce the amount of cost-sharing a member is responsible for — it just spreads those costs out. In 2025, the maximum members could spend on prescription drugs is $2,000. This is true for everyone with Medicare drug coverage, even if they do not join the MPPP.

In the payment plan, when members fill a prescription for a drug covered by Part D, members will not pay their pharmacy (including mail order and specialty pharmacies). Instead, members will get a bill each month from Advantage MD. The monthly bill is based on what the member would have paid for any prescriptions they get, plus their previous month’s balance, divided by the number of months left in the year.

Even though members will not pay for their drugs at the pharmacy, they are still responsible for their costs. If they want to know what their drug will cost before they take it home, members can call us, visit caremark.com or ask the pharmacist.

View a few examples of how the payment plan would work on our website at hopkinsmedicare.com/mppp.

No. Only covered Part D medications will apply toward the MPPP. Members will still be responsible for their cost share at the pharmacy for any non-Part D prescription drugs, such as prescription vitamins, cough and cold medications and erectile dysfunction medicine, or Part B prescription drugs.