Frequently Asked Questions (FAQs)

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 of $590 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 $590 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 — this is the maximum you will spend on covered drugs in 2025. You then move on to the Catastrophic Coverage stage.

After you reach the out-of-pocket maximum of $2,000 for 2025, 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.

No. Johns Hopkins Advantage MD (HMO, HMO D-SNP, PPO, PPO Plus, PPO Primary, and PPO Premier) are Medicare Advantage Prescription Drug plans, also known as Medicare Part C. Our contract with CMS allows us to provide you with all the benefits of Original Medicare, plus coverage to help pay for benefits and services that Medicare doesn’t cover. All Advantage MD plans include prescription drug benefits and extras like vision, hearing, dental, and health and wellness programs. (except HMO Tribute which does not include prescription drug benefits).

No. You will not lose Original Medicare coverage if you enroll in our plan. You’re just choosing to allow a private company to administer your benefits instead of the federal government. You do not lose your Medicare benefits and you must continue to pay your Part B premium.

Your premium will stay the same every month during the calendar year unless you receive a Part D Late Enrollment Penalty (LEP) from the Social Security Administration.

You can pay your premium by using electronic funds transfer (EFT) from your bank account or have it automatically deducted from your Social Security or Railroad Retirement Board (RRB) benefit check. Y ou can also receive a monthly statement.

The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums. You must pay your premium directly to Advantage MD.

Failure to pay your Advantage MD premium will result in being dis-enrolled from the plan. The plan encourages all members to make timely payments, by the first of every month. If a payment is not received for 3 consecutive months you will be dis-enrolled from the plan.

An LEP is an additional charge for not previously being enrolled in a Part D Plan.  The late enrollment penalty is not determined by the Johns Hopkins Advantage MD plan.  This penalty is determined by Medicare for the number of months not enrolled in a Part D Plan, if for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

1. A Medicare Prescription Drug Plan (Part D)
2. A Medicare Advantage Plan (Part C) (like an HMO or PPO)
3. Another Medicare health plan that offers Medicare prescription drug coverage
4. Creditable prescription drug coverage.

Advantage MD offers both HMO and PPO products. With an HMO plan, you must select a primary care provider (PCP) from our network who will coordinate your care. Your PCP will refer you to specialists or hospitals if you require additional care. You must get your care from providers that are in the Advantage MD network; if you go to a provider outside of our network for non-emergency care, you will be responsible for the entire cost.

With a PPO plan, you have the freedom to choose physicians and specialists from within our network, or seek care out of network. If you choose to see a provider that is not in the Advantage MD network, your out-of-pocket costs will be higher.

If you use providers that are not in our network, the plan may not pay for these services. For more information, review your Evidence of Coverage.

Certain medical services and supplies may require approval before they will be covered by your plan, such as specialty medical care, inpatient mental health treatment or inpatient substance-abuse treatment. Your Evidence of Coverage indicates which services, supplies or medications require prior authorization. For Advantage MD PPO, Plus PPO and Premier PPO plans, no prior authorization is required for out-of-network providers eligible to participate in Medicare and most services and supplies as long as the services are covered benefits and medically necessary. All prior authorization requests are coordinated through your primary care physician (PCP), so your provider must ask for and receive approval before you receive care. Johns Hopkins Advantage MD will review the service, drug or equipment to determine the necessity or appropriateness of the services being authorized. If prior authorization is not given, then coverage for care, services or supplies may be limited or denied. For more information on prior authorization guidelines specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

A referral is a written order from your PCP giving you permission to see a specialist or receive certain medical services. For Advantage MD HMO and D-SNP plans, you will need a referral from your PCP before you can see a specialist and be covered for that care. For information on getting a referral for care specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

Yes, our HMO plan requires referrals for specialist visits. Your PCP will help coordinate your care with any
specialists you may require. Johns Hopkins Advantage MD is a Medicare Advantage Plan with a Medicare contract offering HMO and PPO products. Enrollment in Johns Hopkins Advantage MD HMO or PPO depends on contract renewal.

Site of service is a term used to indicate the facility in which you receive care. Many surgical procedures can be performed safely in an outpatient hospital setting, such as an ambulatory surgery center (ASC). Certain procedures require prior authorization when performed in an outpatient hospital setting. For information on covered outpatient services specific to your Advantage MD plan, refer to your Advantage MD Evidence of Coverage.

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.

Advantage MD recommends verifying your provider’s network status regularly and especially before receiving services. It is important to verify because providers can opt out of the plan at any time throughout the year. To check our Provider Directory, please visit www.hopkinsmedicare.com/find-a-provider.

No, it is always best to verify the network status of your specific provider. Providers may have permission to practice at a facility, but may not be contracted with Advantage MD, which can impact the use of your benefits and your out-of-pocket costs. To check our Provider Directory, please visit www.hopkinsmedicare.com/find-a-provider.

If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage. Visit the Social Security Administration’s website (www.ssa.gov) to see if you qualify. Maryland residents may also be eligible for the Senior Prescription Drug Assistance Program (SPDAP). For more information, visit www.marylandspdap.com.

To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in the plan’s service area. The Johns Hopkins Advantage MD (HMO), Johns Hopkins Advantage MD D-SNP (HMO), and Johns Hopkins Advantage MD (PPO) service area includes the following counties in Maryland: Anne Arundel, Baltimore, Carroll, Frederick, Howard, Montgomery, Somerset, Washington, Wicomico, and Worcester.
The Johns Hopkins Advantage MD Plus (PPO) service area include the following counties in Maryland: Anne Arundel, Baltimore, Carroll, Frederick, Howard, Somerset, Washington, Wicomico, and Worcester.
The Johns Hopkins Advantage MD Premier (PPO) service area includes Montgomery County only.
The Johns Hopkins Advantage MD Tribute (HMO) and Johns Hopkins Advantage MD Primary (PPO) service area includes the following counties in Maryland: Anne Arundel, Baltimore, Frederick, Howard, and Montgomery
The Johns Hopkins Advantage MD Select (HMO) service area includes the following counties in Virginia: Arlington, Fairfax City, and Falls Church City.

You must contact Social Security Administration at 800-772-1213, Monday through Friday, 8 a.m. – 5:30 p.m. In addition, you must contact Johns Hopkins Advantage MD Customer Service at 877-293-4998 (HMO) or 877-293-5325 (PPO). From October 1 – March 31, our Customer Service hours are Monday through Sunday 8 a.m. – 8 p.m. From April 1 – September 30, our hours are Monday through Friday 8 a.m. – 8 p.m.

D-SNP stands for Dual Eligible Special Needs Plan. These plans enroll individuals who are entitled to both Medicare and Medicaid. These plans must cover the same Medicare services that all Medicare Advantage plans cover and may also cover extra services. To join a D-SNP plan you must meet the eligibility requirements. To find out more about Johns Hopkins Advantage MD D-SNP (HMO) see your:

2025 Summary of Benefits

2024 Summary of Benefits

To see if you qualify for Medicaid visit www.marylandhealthconnection.gov.