Prescription Drug Coverage
What’s covered?
Find a complete list of the Medicare-approved, prescription brand-name and generic medications we cover in our Comprehensive Formulary.
You may obtain a print version of your formulary by calling us. We are available for assistance 24 hours a day, 7 days a week.
Download the Comprehensive Formulary and related documents, or use our formulary search tool to find drugs that are covered by Advantage MD:
- D-SNP (HMO) formulary – English | Spanish (effective 04/01/2025)
- D-SNP (HMO) D-SNP Formulary Search Tool
- D-SNP (HMO) Prior Authorization Criteria (effective 04/01/2025)
- D-SNP (HMO) Step Therapy Criteria
- Errata (List of Changes to D-SNP (HMO) Formulary) (effective 04/01/2025)
- Errata (List of Changes to HMO Formulary) (effective 04/01/2025)
- Errata (List of Changes to PPO Formulary) (effective 04/01/2025)
- HMO Comprehensive Formulary (effective 04/01/2025)
- HMO Formulary Search Tool
- HMO Prior Authorization Criteria (effective 04/01/2025)
- HMO Step Therapy Criteria
- PPO and Plus (PPO) Comprehensive Formulary (effective 04/01/2025)
- PPO and Plus (PPO) Formulary Search Tool
- PPO and Plus (PPO) Step Therapy Criteria
- PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- Primary (PPO) Comprehensive Formulary (effective 04/01/2025)
- Primary (PPO) Formulary Search Tool
- Select (HMO) Formulary (effective 04/01/2025)
- Select (HMO) Formulary Search Tool
Questions?
We’re a phone call away.
PPO Members:
HMO Members:
Advantage MD covers both Medicare Part B and Part D* medications.
To see examples of Part B and Part D medications and where to obtain the medication, view the Medicare Part B vs. Part D chart below.
Diabetes Supplies
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
|
|
Advantage MD (PPO) and Advantage MD (HMO) members may obtain Part B diabetes testing supplies from an Advantage MD DME provider or any network pharmacy. Advantage MD HMO D-SNP and Advantage MD Tribute members may only obtain Part B diabetes testing supplies from an Advantage MD DME provider. To learn about how to get diabetes testing supplies, call Customer Service. PPO members: call 877-293-5325 (TTY: 711). HMO members: call 877-293-4998 (TTY: 711). Part D diabetes supplies are available from a pharmacy. |
Vaccines
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
Influenza (flu) and pneumonia vaccines are covered by Part B. For other vaccines, if it is directly related to an injury (such as if you stepped on a nail) or risk level, Part B covers the vaccine. |
If your doctor prescribes the vaccine for a reason other than exposure or injury, Part D covers the vaccine and its administration. For example, Shingles vaccine is covered by Part D. |
You may obtain Part D vaccines from your pharmacy. You may obtain Part B vaccines from your provider or a pharmacy. Advantage MD Tribute members may only obtain Part B vaccines from an Advantage MD provider. Refer to Chapter 6 of your EOC for more information. This may require a coverage determination. |
Inhaled Nebulizer Medications (those that you take by inhaling)
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
Medications are covered by Part B when used with a nebulizer in the home. |
Medications are covered by Part D when used with a nebulizer in a skilled nursing facility or as an inpatient in the hospital and your stay is not covered by Part A. |
You may obtain the medication from your provider or a pharmacy. This may require a coverage determination. Advantage MD Tribute members may only obtain Part B drugs from an Advantage MD provider. |
Immunosuppressive Medications
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
If you have received a Medicare covered transplant, medications are covered by Part B. |
If you received a non-Medicare covered transplant or are using these medications for another reason, they would be covered by Part D. |
You may obtain the medication from your provider or a pharmacy. This may require a coverage determination. Advantage MD Tribute members may only obtain Part B drugs from an Advantage MD provider. |
Oral Anticancer Medications
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
If you are being treated for cancer by an oral anti-cancer drug that was once available only in an injectable form that was covered by Medicare, medications are covered by Part B. |
If you are using an oral anti-cancer drug that was once available only in an injectable form that was covered by Medicare for another reason, they would be covered by Part D. |
You may obtain the medication from your provider or a pharmacy. This may require a coverage determination. Advantage MD Tribute members may only obtain Part B drugs from an Advantage MD provider. |
Oral Anti-Emetic Medications
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
When used to treat nausea related to cancer chemotherapy (in place of intravenous anti-emetic drugs) within 48 hours of chemotherapy, medications are covered under Part B. |
For all other indications or when used more than 48 hours after chemotherapy, medications are covered under Part D. |
You may obtain the medication from your provider or a pharmacy. This may require a coverage determination. Advantage MD Tribute members may only obtain Part B drugs from an Advantage MD provider. |
Total Parenteral Nutrition (TPN) Medications
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
When used to treat permanent dysfunction of the digestive tract, medications are covered by Part B. |
For all other conditions, medications are covered under Part D. |
You may obtain the Part B medication from your provider and the Part D medication from a pharmacy. This may require a coverage determination. |
Erythropoietin (EPO)
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
Part B covers EPO products:
|
Part D covers EPO products for:
|
You may obtain the medication from your provider/dialysis center or a pharmacy. This may require a coverage determination. Advantage MD Tribute members may only obtain Part B drugs from an Advantage MD provider. |
Infusible/Injectable Medications
Medications Covered by Part B (medical) |
Medications Covered by Part D (pharmacy) |
Where to Obtain Medication |
|---|---|---|
Medications that are administered at home that require the use of an infusion pump (as specified by the local DME provider) are covered by Part B. |
Medications that do not require the use of a pump (as specified by the local DME provider) or for settings that are not considered a patient’s home (such as a long-term care home with skilled nursing on site) are covered by Part D. |
You may obtain the Part B medication from your provider and the Part D medication from a pharmacy. This may require a coverage determination. |
Diabetes Coverage
Diabetes testing supplies are covered under Medicare Part B.
Supplies like meters, lancets, and test strips can be purchased at a network pharmacy for Advantage MD PPO and HMO members, but nebulizers and other equipment must be purchased through a Durable Medical Equipment (DME) vendor. Advantage MD HMO D-SNP members must purchase diabetes testing supplies through a DME vendor.
If you previously purchased diabetes testing supplies from a pharmacy without using your Advantage MD insurance, you may file a Part B claim to go through the reimbursement process.
About Our Drug Formularies
Our formulary is updated monthly and as formulary changes occur.
Notice of Part D Formulary Updates
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. To view the latest changes that have been made to the formulary, you can download and refer to the errata sheet.
Please Note
In the event that 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.
FORMULARY ALTERNATIVES
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.
Specialty Medications – Medical Benefit
Some medications covered by Advantage MD require prior authorization 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.
Transition Policy
For New Members
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 Members
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 Residents
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 Change
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 Letter
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?
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).
HMO members: 877-293-4998 (TTY: 711).
We are available 24 hours a day, seven days a week.
Important Message About What You Pay for Part B Drugs: Johns Hopkins Advantage MD (HMO/PPO) members will pay less for many Part B drugs. The decrease in price will affect Part B rebatable drugs that have increased at a rate faster than the rate of inflation. Changes to co-insurance amounts are subject to change each quarter. Advantage MD will not charge more than $35 for one-month’s supply of insulin furnished through an item of durable medical equipment (example: insulin pump).
Important 2025 Part D Updates: Starting in 2025, Medicare Part D prescription drug coverage will include significant changes: the removal of the Coverage Gap (“donut hole”), a new $2,000 annual out-of-pocket maximum, an optional Medicare Prescription Payment Plan to help manage costs, and updates to Advantage MD’s prescription drug coverage. Watch the video to learn how these updates can help you prepare for the year ahead!
*Part D is not available for Advantage MD Tribute members.
