0000121073 00000 n *Non-standard services that call for an added fee are not part of the Silver&Fit program and will not be reimbursed. Medicare plans are available to all Medicare beneficiaries. View recent announcements. About Johns Hopkins Medicine. Certain medications have specific dispensing limitations for quantity and maximum dose. $200 supplemental benefit for any injury or illness. The following Johns Hopkins Advantage MD plans offer Medicare Advantage Prescription Drug plan coverage to Maryland residents. PPO/Plus PPO/Premier PPO formulary search toolHMO formulary search toolD-SNP (HMO) formulary search tool. How to request a medical benefit drug prior authorization: All preferred and non-preferred Part B drugs are identified on the Advantage MD Part B Prior Authorization Drug list. 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. %PDF-1.7 % 2. 0000035026 00000 n Read more about coronavirus. Any nonstandard fitness center service that typically requires an additional fee is not included in your basic fitness membership (for example, court fees or personal trainer services). endstream endobj startxref 0000034414 00000 n 0 Information on Coronavirus (COVID-19) At Advantage MD, we want to make sure you have accurate information, know what to expect, and are empowered to care for your own and your family's health. Clinical documentation should be provided to support all requests. Member cost share for Select Insulins will be $35 for a one-month supply and up to $105 for a three-month supply with additional savings for mail order. 0000788916 00000 n 50 0 obj <> endobj 0000018508 00000 n Therefore, if an opioid nave patient attempts to fill more than a seven days supply of an opioid, the prescription will reject at the pharmacy. Log in to your HealthLINK account to view information on yourUSFHP patients. Advantage MD Part B Prior Authorization Criteria. 0000033996 00000 n Enrollment in Johns Hopkins Advantage MD, HMO, PPO or D-SNP (HMO) depends on contract renewal. The Johns Hopkins Medicare Advantage Plans are still the only Medicare Advantage Plans accepted at the renown Johns Hopkins Health Care system. Coverage of these drugs are subject to specific criteria approved by Medicare. Offered throughout most of Maryland, a Johns Hopkins Medicare Advantage plan provides you with comprehensive Medicare coverage including Medicare Part D drug coverage. A top-tier PPO, which features comprehensive dental coverage, is only offered in Montgomery County. 0 Certain medications require prior authorization before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. 0000013598 00000 n Generic drugs are listed in italic type in the formulary. Those having their benefits terminated will lose access to reduced prices for prescriptions, better copays, and access to vision and dental benefits. Members are responsible for the difference between the allowed amount and the billed amount. See the appropriate fax number on the top of the form for submission. Tier 3). $200/day copay for days 1-5; $0 copay for days 6-90; $10 copay once per year; up to $300 allowance for additional eyewear every two years. Find Plans | Get Facts. Overall Government Star Rating 3.0 . trailer Give us a call (410) 896-1212. If a request is denied, an appeal or a redetermination may be filed within 60 calendar days from the date of the first decision. Advantage MD provides coverage for a number of Part B and Part D vaccines. 20% coinsurance for chronic lower back pain. Advantage MD recently launched the Johns Hopkins Advantage MD Benefits Explorer, an interactive tool designed to help Advantage MD members quickly and easily find coverage information related to specific services. Use this search tool to find doctors, hospitals, prescription drugs, and pharmacies within the Advantage MD network. 2. Cost savings does not apply in the catastrophic phase. 0000113770 00000 n Hearing Vision Dental. Find more COVID-19 testing locations on Maryland.gov. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. Medicaid beneficiaries are excluded from this analysis as coverage of supplemental benefits is largely determined by the state. %%EOF They will fax you a drug specific questionnaire for you to complete and return via fax. Search health topics in theHealth Library. EHP/Priority Partners/Advantage MD patients, NM - Not available at mail-order pharmacies. IMPORTANT : This page has been updated with plan and premium data for the 2023 Medicare Annual Enrollment Period (AEP). 0000028820 00000 n . 0000803559 00000 n The provider may request an exception to the step therapy for specific circumstances that warrant a need for a non-preferred product. care coverage, acupuncture allowances, and additional benefits beyond Original Medicare. 77 0 obj <>/Filter/FlateDecode/ID[<0ABEC5C4C8EF4BE4B3D202653CDF91C4><4A630CA9FB2EAC409BE2A68EF5C7D8C0>]/Index[50 49]/Info 49 0 R/Length 125/Prev 193716/Root 51 0 R/Size 99/Type/XRef/W[1 3 1]>>stream For out-of-network benefits, you pay a percentage for most coveredservices. Browse provider manuals. B/D - This drug may be covered under Medicare Part B or D depending upon the circumstances. Our formularies consist of the following cost sharing tiers: Cost Sharing Tier 1: Preferred Generic Drugs have the lowest out-of-pocket cost for members and are placed on Tier 1. This means your patient can fill a100-day supply of Tier 1 medication and a 90-day supplyof Tier 2 through 4 medication for only 2 times the retail copaysaving them an equivalent of four retail copays per year. The members plan determines which formulary applies: Advantage MD PPO/Plus PPO/Premier PPO FormularyAdvantage MD HMO FormularyAdvantage MD D-SNP (HMO) Formulary. Limitations:1. 0000034551 00000 n 0000789385 00000 n If you have any questions, call Customer Service: PPO patients: 877-293-5325 (option 2)HMO and D-SNP patients: 877-293-4998 (option 2). The following section will describe these benefits in detail. Enroll . member is filling opioids and benzodiazepines). Today, with Advantage MD you get a choice of Medicare plans to meet your needs - offering quality benefits, built-in savings, expert care and more. Supplies like meters, lancets, and test strips can be purchased at a network pharmacy, but nebulizers and other equipment must be purchased through a DME vendor. If a non-preferred product is required, an organization determination must be submitted. Johns Hopkins Advantage MD (PPO) Frequently Asked Questions Provider Relations Department: 1-888-895-4998 . PPO Prior Authorization CriteriaHMO Prior Authorization CriteriaD-SNP (HMO) Prior Authorization Criteria. 0000000016 00000 n Cost Sharing Tier 4: Non-Preferred Drugs have a higher out-of-pocket cost for members. Medicare Advantage with Part D plan details and help for Johns Hopkins Advantage MD Premier (PPO) offered by Johns Hopkins Advantage MD. Use the chart below to see your benefits at-a-glance. 0000028930 00000 n Look up plan benefits. Download the applicable Request for Medicare Prescription Drug Coverage Determination form below, complete, and send with clinical supporting documentation. 0000034216 00000 n Hearing Vision Dental. 0000024509 00000 n Advantage MD requires prior authorizationand/or step therapy for certain provider-administered medications to determine medical necessity. If you want a Provider or Pharmacy Directory mailed to you, or if you need help finding an in-network provider, please call Customer Service, October 1 through March 31, Monday through Sunday, 8 a.m. to 8 p.m., and April 1 through September 30, Monday through Friday, 8 a.m. to 8 p.m. PPO network: call 877-293-5325 (TTY: 711) HMO network: call . Contact JHHC. Providers have access to the prior authorization system that allows for intake through a web-based portal, as well as access to real-time status updates. 0000022582 00000 n It is the ordering providers responsibility to determine which specific codes require prior authorization or have step therapy. Advantage MD products are offered by Hopkins Health Advantage, Inc., a Maryland health insurer. Overall Government Star Rating 3.0. out of 5 stars. Not all plans offer all of these benefits. 2023 Johns Hopkins Advantage MD (PPO) - H3890-001- in MD Plan Benefits Explained The Comprehensive Formularies are complete lists of medications we cover and are approved by Medicare. Johns Hopkins Advantage MD D-SNP is an HMO D-SNP plan with a Medicare contract and a State of Maryland Medicaid contract. A dental checkup is good for cleaning your teeth and gums and checking the health of your mouth. endstream endobj 51 0 obj <>>> endobj 52 0 obj <. All members can access wellness programming, including free classes, care management, pregnancy support and more. Advantage MD Premier (PPO) and Advantage MD D-SNP (HMO) You get all the beneits of a comprehensive dental plan included in your premium. You can also download a PDF of your plan's summary of benefits. English | 0000034074 00000 n hb``c``e`a`xAb@qa5DIq@GGkhZGD(_XQ3$ACr1` Enroll on the phone or online! Please note: the information in this section does not apply to AdvantageMD Group. Look for the drug on the list. 0000120547 00000 n For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. The plans website includes apharmacy locator for members and providers to easily locate participating pharmacies. Several of our plans now start at $0 a month with doctor's visits as low as $0 and include . 0000209902 00000 n Advantage MD utilizes multiple formularies which have different cost sharing tiers. 0000088113 00000 n 39 0 obj <> endobj Diabetes testing supplies are covered under Medicare Part B. %%EOF Health Plan Radar . These point-of-sale edits are safety edits and not intended as prescribing limits. ** Base Plan ** Premium Total monthly premium: $130.00 Health plan premium: $64.40 Drug plan premium: $65.60 You must continue to pay your Part B premium. Medicare Advantage combines Part A and Part B. 167 0 obj <>stream Some non-preferred generic drugs are also included. Members are instructed to discuss these dual-purpose items with their prescriber since they are medicines and products that can be used for either a medical condition or for general health and well-being. Johns Hopkins Advantage MD Plus (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Out-of-network/non-contracted providers are under no obligation to treat Johns Hopkins Advantage MD members, except in emergency situations. Explanation of Hearing Aid Coverage Johns Hopkins Advantage MD covers up to two hearing aids per year when purchased through TruHearing. 0000111876 00000 n Don't forget that new CMS regulations require disclosures . To find the quantity limit for certain medications, please refer to the appropriate formulary/formulary search tool. 0000208904 00000 n If you are not able to pay your bill in full, you may qualify for a payment plan and/or financial assistance. 0000034857 00000 n Dental claims or specific plan details: United Concordia at 866-851-7576 Initial Coverage Phase After you pay your deductible, if applicable, up to the initial coverage limit of $4,430. Providers are encouraged to prescribe the following lower cost Select Insulins. Dental Checkup - Johns Hopkins Advantage MD Enroll Now Dental Checkup What is this visit? Pharmacies may request opioid prescribers to submit a Coverage Determination for prescriptions for opioid nave members when days supply exceeds seven days. All rights reserved. The retail pharmacy network includes over 65,000 pharmacies nationwide. TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security. Tier 5 (Specialty Tier) medications are exempt from tier exception. 31 - Monday through Sunday, 8 a.m. to 8 p.m. and Apr.1 through Sept. 30 - Monday through Friday, 8 a.m. to 8 p.m. &/I&09LHH"8Hi{Xf$ @ yBF0 Hy Our formularies are updated on a monthly basis or whenever formulary changes occur. Prior authorizations are required for the following:endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full orpartial). * Amenities offered by fitness centers vary by location. Part A and Part B are also known as "Original Medicare". Johns Hopkins Advantage MD Premier (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Information may need to be submitted describing the use and setting of the drug to make the determination. 0000085641 00000 n Please see the most recent comprehensive formulary document for verification of formulary status. 0000011935 00000 n CVS/caremark sends a three month supply of maintenance medications in one fill, making it easier for the patient only having to fill four times a year. Please review the applicable formulary and corresponding cost sharing tiers (copays) to confirm coverage. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). Johns Hopkins Advantage MD (PPO) has an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. 0000792509 00000 n Clinical documentation should be provided to support all requests. Contact us or find a patient care location. Ready to Enroll Online? Get the Facts on Medicare . 0000002119 00000 n Johns Hopkins Advantage MD administers Part D Pharmacy Benefits for the following members: FormulariesCost Sharing TiersPrior Authorization, Quantity Limits, and Step TherapySelect Insulins for Reduced Copays New 2022 BenefitExceptionsAppeals (Redetermination)Opioid EditsMedical InjectablesOver the Counter Program New 2022 Benefit. Advantage MD is committed to delivering cost effective quality care to our members. How do I determine if a specific treatment requires prior authorization or has step therapy? Maintenance medication on cost sharing tier 1 may be obtained for a 100 day supply and medications on cost sharing tier 2 through tier 4 may be obtained for a 90 day supply. The Advantage MD formularies are subject to change at any time upon Medicare approval. For a complete comparison of which medications are covered by which part, please refer to the Medicare Part B vs. Part D chart. This plan = Part A + Part B + Part D Plan Details Monthly Premium $30 Health Portion of Premium $12 hLKa?wIpdAdGAQK01Z Z$pl@y>} OgD(,|v}hcrl{oHb+Nz`0n=]721WeBuuHfrRLKR{"2$DfT|IU#[?DP}JC>z9*3Zm9*pE5Nal B][q1~tv: T 0000012661 00000 n If you prefer to work out at home in lieu of a participating fitness center, you have the option to enroll in the Silver&Fit Home Fitness Program and receive up to two home fitness kits each benefit year at no charge. 0000216199 00000 n <<9EC50185E05A7140916CD6EA14CECE41>]/Prev 1587548>> LifeBridge Health, along with five other of the region's most notable health systems, recently became an equity partner in Johns Hopkins Medicare Advantage health plans, making LifeBridge Health a part owner of the Hopkins Medicare managed insurance plans Advantage MD and Advantage MD Plus. Please utilize HealthLINK to submit prior authorization requests or step therapy exceptions for Medicare Part B drugs. Have Questions About Your Bill? For more information, please review the Evidence of Coverage. Clinical documentation should be provided to support all requests. 0000027093 00000 n 0000025072 00000 n To file a request by phone, call Customer Service toll-free, 24 hours a day, seven days a week. Specialty Tier drugs have a coinsurance and are limited to a 30 day supply. 8 a.m.-8 p.m., 7 days a week. If you have any questions, please contact Customer Service at 877-293-5325. 0000121585 00000 n We are vaccinating all eligible patients. 0000024692 00000 n 0000209468 00000 n To find if a drug requires a Step Therapy and criteria, please refer to the appropriate formulary/formulary search tool. Only non-Low Income Subsidy (LIS) enrollees are eligible for the reduced cost-sharing. 0000013153 00000 n Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent, objective medical criteria. PPO members: 877-293-5325 (option 2)HMO members: 877-293-4998 (option 2). 2. In addition, a three month supply of maintenance medication on Tier 1 through 4 is available through CVS/caremark mail order at a reduced copay. So wherever life takes you, we're here to help. Johns Hopkins Advantage MD is a Medicare Advantage Plan with a Medicare contract offering HMO and PPO products. Contact customer service at 1-855-662-3017. The comprehensive dental benefit for the Johns Hopkins Advantage MD D-SNP (HMO) plan has a $500 Annual Maximum. For more information, please review the Evidence of Coverage. Limitations:1. $20 copay (cleaning); $20 copay (oral exam); $20 copay (dental x-ray), $15 copay (cleaning); $15 copay (oral exam); $15 copay (dental x-ray), $0 copay (cleaning); $0 copay (oral exam); $0 copay (dental x-ray). For detailed information on what each individual plan offers, visit benefits.hopkinsmedicare.com, or see the summary of benefits: 0000012697 00000 n Available for an extra premium ($25) for comprehensive dental. Use of the word "senior" or the number "65" does not imply that Medicare plans are only available to seniors. *Please note: this information does not apply to AdvantageMDGroup. Advantage MD covers up to $90 every three months for D-SNP (HMO) members and up to $60 every three month for HMO members. Evidence of coverage of all plan-covered OTC drugs, supplies, and even gym memberships both Part. Including the cost-sharing that applies to you: Switch between Advantage MD website the and! B drugs 7 days a week PPO step therapy Exceptions can be requested when a condition! 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