2025 Part D Coverage Determinations and Appeals
Looking for 2024 Part D Coverage Determinations and Appeals?
Plan Specific Resources
Advantage MD PPOCollapse
- PPO and Plus (PPO) Prior Authorization Criteria – (effective 01/01/2025)
- PPO and Plus (PPO) Step Therapy Criteria
- PPO Formulary – English | Spanish
- Primary (PPO) Comprehensive Formulary –(effective 01/01/2025)
- PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- PPO Formulary Search Tool
- Primary (PPO) Formulary Search Tool
Advantage MD HMOCollapse
- HMO Prior Authorization Criteria – (effective 01/01/2025)
- HMO Step Therapy Criteria
- HMO Formulary – (effective 01/01/2025)
- HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- HMO Formulary Search Tool
Advantage MD D-SNP (HMO)Collapse
- D-SNP (HMO) Prior Authorization Criteria – (effective 01/01/2025)
- D-SNP (HMO) Step Therapy Criteria
- D-SNP (HMO) Formulary – English | Spanish – (effective 01/01/2025)
- D-SNP (HMO) Paper Prescription Drug Coverage Determination Request – English | Spanish
- D-SNP (HMO) Prescription Drug Coverage Redetermination Request – English | Spanish
- D-SNP (HMO) Formulary Search Tool
Advantage MD Select (HMO)Collapse
- HMO Prior Authorization Criteria – (effective 01/01/2025)
- HMO Step Therapy Criteria
- Select (HMO) Formulary – (effective 01/01/2025)
- HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- Select (HMO) Formulary Search Tool
Frequently Asked Questions
What is a coverage determination (prior authorization)?Collapse
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.
- PPO and Plus (PPO) Prior Authorization Criteria
- HMO Prior Authorization Criteria
- 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:
- PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 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
What is a step therapy requirement?Collapse
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.
- 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
What is a quantity limit?Collapse
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.
- PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- Online Medicare Prescription Drug Coverage Determination Request
What are exceptions?Collapse
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.
How will I know if a prior authorization, quantity limit, or step therapy requirement applies to a drug I take?Collapse
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.
- 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 – English | Spanish
- HMO Formulary
- Primary (PPO) Formulary
- D-SNP (HMO) Formulary
- 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).
How do I submit exceptions and coverage determination (prior authorization) requests?Collapse
Submit online:
Paper request:
- 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
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.
How do I submit an appeal for a denied coverage determination or exception request?Collapse
We accept standard and expedited requests by telephone and in writing.
Submit online:
Paper request:
- PPO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- HMO Paper Prescription Drug Coverage Redetermination 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
How long before I get an answer to my exception request?Collapse
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.
What is a grievance?Collapse
A “grievance” is a complaint that does not involve a coverage determination. You have the right to file a “grievance” or make a complaint if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.
How do I submit a grievance?Collapse
Phone:
To file a medication or pharmacy-related grievance, you may 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).
Fax:
1-866-217-3353
Mail:
If you do not wish to fax or call, you can put your complaint in writing and send it to us at:
Johns Hopkins Advantage MD
c/o CVS/Caremark Part D Services
Medicare Part D Grievances Department
P.O. Box 30016
Pittsburgh, PA 15222-0330
If you put your complaint in writing, we will respond to your complaint in writing.
Submit online to Medicare:
Your Advantage MD plan has a dedicated Customer Service department that can help you with any questions or complaints you have. If at any time you have any feedback for us or if you have questions about your medication coverage, please call our Customer Service 24 hours a day, seven days a week.
PPO members: call 877-293-5325 (TTY: 711).
HMO members: call 877-293-4998 (TTY: 711).
For additional information on how to make a complaint, please refer to your EOC.
What is an appointment of representative?Collapse
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.
How do I assign an appointment of representative?Collapse
To assign an appointment of representative, download, print, and complete the form and mail to either of the following locations.
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).
Quality Assurance Policy
Our Utilization Management and Quality Assurance Program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. Johns Hopkins Advantage MD offers this program at no additional cost to its members and their providers.
Utilization Management
Our Utilization Management Program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, quantity limits, and step therapy. Learn more about Utilization Management.
Medication Therapy Management Program
The Johns Hopkins Advantage MD Medication Therapy Management (MTM) Program helps you get the greatest health benefit from your medications by preventing or reducing drug-related risks, increasing your awareness, and supporting good habits. The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medications. The MTM program helps you and your doctor make sure that your medications are working to improve your health. Learn more about Medication Therapy Management.
Quality Assurance
As a part of our Quality Assurance Program and to improve the quality of care surrounding prescription drugs, Johns Hopkins Advantage MD uses a Drug Utilization Review (DUR) program to determine the effectiveness, potential dangers, and/or interactions of your medication(s). Our purpose is to promote patient safety by effectively communicating with pharmacies when prescriptions are filled to identify any drug interactions or warning signs. If there is a risk to your health, we will immediately communicate with the dispensing pharmacy.
Additionally, we also communicate with dispensing pharmacies when other alerts occur:
- Duplicate therapy
- Over or under-utilization
- Use of multiple pharmacies and prescribers
- Incorrect drug dosage or duration
- Clinical abuse/misuse
- Appropriate use of generic products
This program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use and may contact you or your doctor regarding quality initiatives as necessary.
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