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Johns HopkinsAdvantage MD 2022HMO and PPO PlansPresented by: Johns Hopkins HealthCare Provider Relations Department
Advantage MD Product OverviewHMO, PPO,PPO Plus,PPO Premier & Group
Agenda Our MissionAdvantage MD OverviewAdvantage MD - Service Area, Medical Benefit OverviewProduct DifferentiationNew for 2022Advantage MD Product Overview – HMOAdvantage MD Product Overview – PPO,PPO Plus,PPO Premier,PPO Group Advantage MD Dental andVision Coverage Telemedicine Requirements, Processes and Important Information for allAdvantage MD Plans Health Care Performance Measures JHHCWebsite and Contact Info
Our Mission Our mission is to improve the health of our membersand provide them with high quality service and care. Provider office staff and physicians play a critical role inthe member’s experience with our plan. With our provider partners, we aim to deliver world-classhealth care to our members while helping them to navigatethe health care continuum. Additional details can be found in the Advantage MDProvider Manual at www.jhhc.com
Johns Hopkins Advantage MD Service AreaService Area is defined as a geographic area where a health plan can accept members.– Anne Arundel County– Baltimore County– Carroll County– Frederick County– Howard County– Montgomery County– Somerset County– Washington County– Wicomico County– Worcester CountyNOTE: Advantage MD Group is available inDelaware, District of Columbia,Florida, Georgia, Maryland, North Carolina,Pennsylvania, South Carolina and Virginia
Medical Benefit Overview Our plans cover all services covered under Original Medicare. We also offer benefits beyond Original Medicare: Preventive dental, routine vision, routine podiatry,hearing exam and low-cost hearing aids Our PPO Plus, Premier and Group plans offer acupuncturecoverage, fitness, routine chiropractic services, worldwideemergency and urgent coverage. Our HMO, PPO and PPO Plus plans have dental and fitnessbenefits. Our HMO plan offers post-discharge meal services tomembers who have been discharged from an inpatient orskilled nursing facility (SNF) stay, coordinated by JohnsHopkins Health Services.
Differences Between HMO & PPO PlansHMO Primary care physician (PCP) coordinates all care for themember. All care must be within the plan network (no out-ofnetwork coverage), unless in an emergency situation. Lower out-of-pocket costs Monthly premiums are lower than PPO plans. Referrals are required for specialty care only; please providea copy to the patient and submit to JHHC.
Differences Between HMO & PPO PlansPPO, PPO Plus, PPO Premier & Group Flexibility in choosing physicians and specialists Monthly premium higher than HMO plans No referrals needed, but higher out-of-pocket costs thanHMOs Coverage outside of the plan network (cost sharing may behigher) Robust supplemental benefits with premium products
Advantage MD PPO 2022 Group BenefitsThe Group plan is available to eligible Johns Hopkins Health System retiredemployees and families who reside in Delaware, District of Columbia, Florida,Georgia, Maryland, North Carolina, South Carolina, and Virginia. Plan Overview- Low monthly premium ( 175)- Low in-network maximum out-of-pocket ( 300)-Worldwide emergency and urgently needed servicescoverage ( 50,000 combined limit annually)-Visitor/Traveler benefit (ability to reside outside of the servicearea less than 12 months, remain in plan and receive in-networkcost sharing anywhere in the United States).- Comprehensive dental coverage- Routine podiatry and chiropractic services- Acupuncture allowance
Advantage MD PPO Member ID CardsFrontBackNote:The circled section will vary depending on selected plan.
Advantage MD HMO Member ID CardsFrontBack
Johns Hopkins Advantage MDNew for 2022HMO D-SNP and Plan Overviews
New for 2022: Johns HopkinsAdvantage MD D-SNP HMO Aligning with JHHC’s Mission and Vision, we are expanding ourMedicare benefit options to target the needs of the underserveddual eligible population by adding a Dual Special Needs Plan (DSNP) called Johns Hopkins Advantage MD D-SNP HMO. The Centers for Medicare & Medicaid Services (CMS) requiresProvider Training for health plans delivering coordinated careand care management to Special Needs Plan (SNP)beneficiaries. Please contact your Network Manager to findout more about online training opportunities for D-SNP.
SNP Plans: General InformationCenter for Medicare and Medicaid Services (CMS) Special NeedsPlans (SNPs) are a specific type of Medicare Advantage coordinatedcare plan that provide targeted care to individuals with unique specialneeds.CMS defines 3 SNPs that serve the following types of members: Individuals with chronic conditions (C-SNP) Individuals who are institutionalized or eligible for nursing home care (I-SNP) Dually eligible members (D-SNP)Medicare beneficiaries enrolled within SNP have customized benefitdesigns to meet the needs of the target population.SNPs have most of the same Medicare Advantage regulations, withsome exceptions, and use the same payment methodology as otherMedicare Advantage plans
SNP Plans: General Information(continued)SNPs were developed by CMS with the intention of enrollingtargeted high-risk populationsSome key differences between DSNP and standard MedicareAdvantage include: D-SNPs can limit enrollment to targeted special needsindividuals D-SNPs beneficiaries can enroll and dis-enroll at anytimethroughout year Approved Model of Care (MOC) required Must offer Part D coverage
Dual Special Needs MembersD-SNP members are those who are eligible for bothMedicare and Medicaid (dual eligible). Qualify for Medicare because of age (65 or older) or dueto a disability. Eligible for Medicaid because they meet the requirementsto qualify for Medicaid in the State of Maryland.JHHC is offering a D-SNP benefit option for dualeligible beginning January 1, 2022
Where JHHC D-SNP Members LiveJHHC offers D-SNP to beneficiaries in the following Marylandcommunities:- Anne Arundel County- Howard County- Montgomery County
D-SNP Model of CareCMS requires D-SNP programs to develop a Model of Care (MOC)framework focusing on four areas- Population Analysis, CareManagement, Provider Network, and QualitySNP Programs must offer provide initial and annual training to healthplan staff and providers.
D-SNP Administrative Components:Member BenefitsMedicaidMedicareJohns Hopkins Medicare Advantage D-SNPBenefits are defined in the plan Evidence ofCoverage (EOC). This document is providedto each member and is published on ourwebsite esMedicaid paysafter MedicareBenefits(20%)
D-SNP Administrative Components:Member Benefits (continued)A sampling of available benefits: Medical and behavioral health services Part D Pharmacy Prescription Drug program Fitness programs Over-the-Counter (OTC) medication catalog Home meals delivery after inpatient discharge Dental care Routine vision Hearing 24/7 nurse-advice telephone line Transportation support to sPrimaryCoverage(80%)Medicaid paysafter MedicareBenefits(20%)DualEligibles
D-SNP Billing Information Per the Johns Hopkins Advantage MD participating provider agreement,participating providers may not deny services to D-SNP members JHAdvantage MD should be billed for 80% of the charges for services providedto D-SNP members. The provider would need to either bill Medicaid for theremaining 20% or accept JH Advantage MD payment in full (80%). If a provider is not registered with Maryland Medicaid, we recommend theydo so they can bill for services provided to D-SNP members. The D-SNPmember may not be billed and is held harmless.
D-SNP Administrative Components:JHHC D-SNP Part D Pharmacy Program Advantage MD D-SNP HMO members have their own formulary,which is different than the formularies for PPO and HMO. Providershould check the Advantage MD D-SNP (HMO) formulary forcovered drugs prior to prescribing for D-SNP members. Most D-SNP members will have low-income subsidy (LIS) andtherefore the deductible and 25% coinsurance for drugs on Tiers 2through 5 will not apply. Members will be responsible for thelessor of their LIS copay or the 25% coinsurance. Mail order for prescriptions is available to D-SNP members. D-SNP members cannot obtain diabetic supplies from a pharmacy.Members must order diabetic supplies from a JHHC DurableMedical Equipment (DME) company. For a list of participatingDMEs, go tohttps://www.hopkinsmedicine.org/johns hopkins healthcare/downloads/amd/advantage md dme provider directory.pdf
D-SNP Administrative Components:Enrollment and EligibilityD-SNP beneficiaries can enroll and dis-enroll any timethroughout the year:D-SNP is contingent on Medicaid eligibility.
D-SNP Administrative Components:Eligibility VerificationAdvantage MD D-SNP Identification Cards FrontBack Each member is provided with an individual member identification card that includes the member’sidentification number, plan, certain copayment information, and effective date. Since changes dooccur with eligibility, the card alone does not guarantee that the member is eligible. Therefore, it isimperative to check eligibility. You must call the health plan or use the HealthLINK online portal toverify eligibility .Customer Service at 877-293-4998HealthLINK account at http://www.jhhc.com/advantagemd
D-SNP Administrative Components:Authorization and Referrals Medical Management staff is accessible at least eight hoursdaily (with the exception of holidays), between 8 a.m.to 5p.m. Eastern Time, Monday through Friday Confidential voicemail and secure fax capabilities will beprovided during and after regular hours of operation. The Medical Management offers TDD/TTY services for deaf,hard of hearing or speech impaired members. Language assistance/ interpretation is available for members
D-SNP Administrative Components:Other Processes & Procedures The following processes and procedures are the samefor D-SNP as they are for other JH Advantage MD PPOand HMO plans. Please check the Advantage MDProvider Manual for more details. Precertification and notification Prior authorization for certain services and review of requestsfor authorization for elective hospital admissions as outlinedin the Evidence of Coverage (EOC). Medical Management evaluation requests for servicesregarding medical care, behavioral health, and substanceabuse treatment Claims submission Appeals and grievances Compliance and Fraud, Waste and Abuse (FWA)
D-SNP Administrative Components:Provider EducationA Provider Education Training Presentation for the JohnsHopkins Advantage MD D-SNP HMO is available on ourwebsite’s Provider Education page:To view the training, please visit:https://www.hopkinsmedicine.org/johns hopkins healthcare/providers physicians/resources guidelines/provider-education.html
New for 2022 Plan Overview: COVID-19Johns Hopkins Advantage MD will pay for theCOVID-19 vaccine and its administration(including approved booster doses), without costsharing, beginning January 1, 2022 for membersenrolled in their plans. For the most current information on Covid-19related services, codes, policies and reimbursementschedules, please visit JHHC’s Covid-19 informationpages athttps://www.hopkinsmedicine.org/johns hopkinshealthcare/providers physicians/covid 19/
New for 2022 Plan Overview : ReducedCopays on Select InsulinsAdvantage MD HMO, PPO, PPO Plus, and PPO Premier plansare participating in the CMS Medicare Part D Senior SavingsModel Program, which offers reduced copays on select insulins. Cost savings will apply to a select list of insulin productsduring the initial and coverage gap stages. Cost savings does not apply in the catastrophic phase. Member cost share for Select Insulins will be 35 for a onemonth supply and up to 105 for a three-month supply withadditional savings for mail order.
New for 2022 Plan Overview: ReducedCopays on Select Insulins (continued) Providers can find out which drugs are Select Insulins byreviewing the Advantage MD Formulary. Select Insulins are indicated on the Drug List with “SI.” Providers are encouraged to prescribe lower cost SelectInsulins. Only non-Low Income Subsidy (LIS) enrollees are eligible forthe reduced cost-sharing. LIS members will pay their normalLIS copay for the Select Insulins.
New for 2022 Plan Overview:Over-the-Counter ProductsAdvantage MD will provide an over-the-counter (OTC) benefitfor members in HMO and HMO DSNP. A wide selection ofdrugs, supplies, and self-care products are provided without aprescription through the plan’s OTC benefit. Examples of OTCitems include, but are not limited to: First aid and medical supplies Cough, cold and allergy Pain relievers and sleep aids Personal care Antacids, digestive care and laxatives Vitamins and minerals Eye, ear, and dental care Skin care Mobility and safety
New for 2022 Plan Overview:Over-the-Counter Products Members can select and order OTC products from theAdvantage MD OTC catalog. Advantage MD covers up to 90 every three months forHMO DSNP members and up to 60 every three month forHMO members. Any unused amount does not carry over tothe next period. Available products and brands may change throughout theyear and are subject to availability. Certain products are identified in the catalog as DualPurpose. Members are instructed to discuss these dualpurpose items with their prescriber since they are medicinesand products that can be used for either a medical conditionor for general health and well-being. Providers should discuss all OTC products with their patientsbut do not need to submit anything to the plan.
New for 2022 Plan Overview:Over-the-Counter Products The Advantage MD catalog for OTC items is available onlineat www.hopkinsmedicare.com. The OTC catalog contains a complete listing of all plancovered OTC drugs, supplies, and self-care products and theprice of each item. Members can have OTC products mailed to their homesonce a quarter after placing an order online atwww.cvs.com/otchs/amd or via the OTC Program call centerat 1-888-628-2770.
2022 Plan Overview: TelemedicineAdvantage MD members can access care viatelemedicine with Johns Hopkins OnDemand VirtualCare (powered by Teladoc) gives members access toan urgent care medical visit 24/7 from the comfort oftheir home, or anywhere they may travel in the UnitedStates.JHHC encourages members to utilize their primarycare provider when possible, but Johns HopkinsOnDemand Virtual Care is an alternative option toquickly access needed care.
2022 Plan Overview:Telemedicine (continued)The Johns Hopkins OnDemand Virtual Care serviceis as an online telemedicine platform for both adultand pediatric patients. It is available to membersthrough mobile app, computer or tablet. The service is intended for minor care concernsthat don’t require lab work, such as colds,rashes and pinkeye. The service is not for medical emergencies. If amember is experiencing a medical emergency, theyshould call 911 or go to the nearest emergencyroom.
2022 Plan Overview: NovoLogix Preauthorization is required for the medical injectabledrug codes listed in the below link for Johns HopkinsAdvantage MD. The process for obtaining prior authorizations for JohnsHopkins Advantage MD is managed in collaboration withCVS Health–NovoLogix. List of applicable codes for Advantage MD, EHP andPriority Partners.7/26/2022CONFIDENTIAL - INTERNAL USE ONLY22
2022 Plan Overview:NovoLogix (continued)How to Request Prior Authorization: Providers may submit preauthorization requestselectronically by accessing the NovoLogix portal throughthe JHHC HealthLINK portal. The Novologix portal mustbe accessed through HealthLINK for JHHCpreauthorization requests. For Advantage MD, providers may also contactNovoLogix by phone if there are issues with theNovologix portal:Advantage MD: 800-932-70137/26/2022CONFIDENTIAL - INTERNAL USE ONLY23
2022 Plan Overview: eviCoreJohns Hopkins HealthCare LLC (JHHC) has partnered witheviCore healthcare to provide patients with access to highquality, medically appropriate care that is consistent withevidence-based treatment guidelines. Providers in the Johns Hopkins Advantage MD network arerequired to use the JHHC-eviCore system to obtain priorauthorization for High Tech Radiology and CardiologyAdvanced Imaging services. Providers should submit prior authorization requests via theeviCore portal or, if the portal cannot be accessed, by callingeviCore at 866-220-3071.
Advantage MD Changes 2022Product Design ChangesHMOPPOPPO PlusPPO Premier 30 100 125 301Inpatient Hospital Coverage 325 days 1 to 5 330 days 1 to 6 330 days 1 to 6 200 days 1 to 5Inpatient Hospital (Mental Health) 325 days 1 to 5 330 days 1-6 330-1-5 250 days 1 to 5PCP 0 5 0 0Specialist 45 50 40 25Urgent Care 50 40 40 40Diagnostic Services/ Lab / Tests/Radiology 20 30 30 10 (Services andLab)Dental –Medicare covered dentalservices 20 20 15 0 Copay - IN 20 Copay IN 20 Copay - IN50% Coinsurance - OON 15 Copay - IN30% Coinsurance - OON 0 Copay IN & OONPremiumDental –Oral Exam, PreventiveCleanings and X-ray(s)
Advantage MD Product tHospitalHMOPPOPPO PlusPPO PremierPPO Group 307550 - IN 325 days 1-5 0 45 300 (Outpatient) 225 (ASC) 100 7,550 / 11,300 330 days 1-6 5 50 300 (Outpatient) 225 (ASC) 130 7,550 / 11,300 330 days 1-6 0 40 300 (Outpatient) 225 (ASC) 301 7,550 / 11,300 200 Days 1-5 0 25 300 (Outpatient) 225 (ASC) 175 3,000 / 10,000 250 days 1-7 5 30 300 (Outpatient) 225 (ASC)ERUrgent CareSupplementalBenefits 90 90 50 40PodiatryPodiatryPreventive DentalPreventive DentalHearingHearingVisionVisionPost-Discharge Meals Expanded TelehealthExpanded TelehealthSilver&FitSilver&FitOver-the-Counter (OTC)Transportation supportRX 0/ 10/ 47/ 100/33% 4/ 12/ 47/ 100/33% 4/ 12/ 47/ 100/33% 0/ 10/ 40/ 90/33% 4/ 12/ 42/ 92/33%No DeductibleNo DeductibleNo DeductibleNo DeductibleOptional RiderComp Dental 25No Dental WaitingPeriodComp Dental 25No DentalWaitingPeriod 90 40PodiatryPreventive DentalHearingVisionChiropracticAcupunctureExpanded TelehealthSilver&FitComp Dental 25No DentalWaitingPeriod 90 90 40 ureAcupunctureFull DentalFull itVisitor / TravelerVisitor / TravelerExpanded Telehealth Expanded Telehealth--
Advantage MD Product DifferentiationHMO Premium 30 MOOP 7,550 IN Residents of Anne Arundel,Baltimore, Carroll,Frederick , Howard,Montgomery, Somerset,Washington, Wicomico,Worcester Low IN cost-sharing to reducebarriers to care Reduced some copayments tomeet FFS schedule Supplemental Benefits Preventive Dental Vision Exam and Eyewear Hearing Exam and Aids Post-Discharge Meals Expanded Telehealth Silver & Fit Over-the-Counter (OTC) Transportation supportPPOPPO PlusPPO Premier Premium 100 MOOP 7,550 IN / 11,300 OON Premium 130 MOOP 7,550 IN / 11,300 OON Premium 301 MOOP 7,550 IN / 11,300 OON Residents of Anne Arundel, Residents of Anne Arundel, Residents of MontgomeryBaltimore, Carroll, Frederick ,Howard, Somerset, Washington,Wicomico, WorcesterBaltimore, Carroll, Frederick ,Howard, Somerset, Washington,Wicomico, Worcester IN lower than OON cost-sharing Reduced some copayments to IN lower than OON cost-sharing Reduced some copayments tomeet FFS schedule Supplemental Benefits Preventive Dental Vision Exam Hearing Exam and Aids Expanded Telehealth Silver & Fitmeet FFS schedule Supplemental Benefits Acupuncture Chiropractic Preventive Dental Vision Exam and Eyewear Hearing Exam and Aids Silver&Fit Worldwide ER and UC Expanded TelehealthCounty only IN and OON cost-sharing thesame No to low cost-sharing on allbenefits Supplemental Benefits Acupuncture Chiropractic Full Preventive andComprehensive Dental Enhanced Vision Enhanced Hearing Silver&Fit Worldwide ER and UC Visitor / Traveler Benefit Expanded Telehealth
Vision and DentalProvider Education 2022Benefits Overview
Vision PPO Coverage Overview 2022 Advantage MD PPO covers additional You may electronically submit claimsvision benefits through SuperiorVision.via the Superior website(www.superiorvision.com) or in the The in-network benefit is coveredonly if the member visits a SuperiorASC X12N 837 HIPAA standardcontracted provider.format,either directly to the Superioror through its clearinghouse.You may Providers who do not participate withalso utilize the CMS 1500 form forSuperior can still see Advantage MDPPO members when there is an outsubmitting paper claims to Superior orof-network benefit under the PPOmail them to:products.Claims DepartmentSuperiorVision939 Elkridge Landing Rd,Ste.200Linthicum,MD 21090Please refer to the“Claim Submission Requirements”section of the Provider Manual for further details onsubmitting claims,as well as the Superior’sreimbursement policies.
Vision HMO and PPOCoverage Overview (2022)ServiceAdvantage MDHMOAdvantage MDPPOAdvantage MDPPO PlusAdvantage MDPPO PremierAdvantage MDGroupRoutine Eye ExamIN: 0 member costOON: No coverageIN: 0 member costOON: 50% membercoinsuranceIN: 0 member costOON: 45% membercoinsuranceIN: 10 membercost OON: 0member costIN: 0 member costOON: 45% membercoinsuranceEyewear 150 towardseyewear or contactslenses every twoyears from anysourceNot Covered 150 towardseyewear or contactslenses every twoyears from anysource 300 towardseyewear or contactslenses every twoyears from anysource 300 towardseyewear or contactslenses every twoyears from anysourceThe routine eye exam and eyewear benefit is processed through Superior Vision.For questions related to the benefits and claims process, please contact Superior at866-819-4298.
Dental HMO Coverage Overview 2022 Advantage MD covers additional dentalbenefits through DentaQuest. The in-network benefit is covered only ifthe member visits a DentaQuestcontracted provider . There is an optional supplemental packageavailable to members in theAdvantage MDHMO plan that offers comprehensivedental coverage (additional monthlypremium) in- and out-of-network. For questions related to thebenefits,prior authorizations,and claims,please contactDentaQuest at 800-471-7140.
Dental Coverage Overview 2022ServiceAdvantage MD HMOAdvantage MD PPOAdvantage MD PPO PlusAdvantage MD PPOPremierAdvantage MD GroupPreventive Dental (In-networkcovered through DentaQuestnetwork)IN: Cleaning (1 per year) 20copayDental X-Ray (frequencydepends on type of services) 20 copayOral Exam (frequency dependson type of services) 20 copayIN: Cleaning (2 per year) 20copayDental X-Ray (frequencydepends on type of services) 20 copayOral Exam (frequency dependson type of services) 20 copayIN: Cleaning (2 per year) 15copayDental X-Ray (frequencydepends on type of services) 15 copayOral Exam (frequency dependson type of services) 15 copayIN: Cleaning (2 per year) 0copayDental X-Ray (frequencydepends on type of services) 0 copayOral Exam (frequency dependson type of services) 0 copayFluoride (2 per year) 0 copayIN: Cleaning (1 per year) 15copayDental X-Ray (frequencydepends on type of services) 25 copayOral Exam (frequency dependson type of services) 25 copayOON: No CoverageOON: 50% coinsuranceOON: 30% coinsuranceOON: 0 copayOON: 45% coinsuranceAdditional 25 a monthpremiumAdditional 25 a monthpremiumAdditional 25 a monthpremiumIncluded at no extra monthlypremiumIncluded at no extra monthlypremiumIN: 50 to 100 copayOON: 50 to 100 copayIN: 50 to 100 copayOON: 50 to 100 copayIN: 50 to 100 copayOON: 50 to 100 copayIN and OON: 0 copayIN: 50 to 400 copayOON: 50% to 70% coinsuranceCovers extractions, rootcanals, crowns, oral surgery,dentures, and moreCovers extractions, rootcanals, crowns, oral surgery,dentures, and moreCovers extractions, rootcanals, crowns, oral surgery,dentures, and moreMaximum plan coverage 1,000annuallyMaximum plan coverage 1,000annuallyMaximum plan coverage 1,000annuallyComprehensive Dental (Innetwork covered throughDentaQuest network)Same cost IN or OONCovers extractions, rootcanals, crowns, oral surgery,dentures, palliative treatment,tissue conditioning, protectiverestoration, consultations, andmoreMaximum plan coverage 1,500annuallyFor questions related to the benefits, prior authorizations, and claims,please contact DentaQuest at 800-471-7140.Covers extractions, rootcanals, crowns, oral surgery,dentures, and moreMaximum plan coverage 1,200annually
Important Benefits Information PPO members can go in-network or out-of-network. HMO members can only go to in-network providers. The formularies for the PPO and HMO products are not thesame. Please review the applicable formulary prior toprescribing. Advantage MD members have a 0% coinsurance for innetwork diabetic supplies. Members can save money on medications by getting a long-termsupply at either a retail pharmacy or through mail order. Johns HopkinsAdvantage MD offers MedicationTherapyManagement (MTM) services at no cost to members throughCVS/caremark. Some services and supplies will require prior authorization.
Johns HopkinsAdvantage MDRequirements, Processes andImportant Information forAll Plans
HMO Referral Requirements Referrals are required for specialty services only. Referrals should be to in-network specialty providers only –there is no out-of-network coverage for HMO. Primary care physicians (PCPs) should complete referrals inHealthLINK and provide the member with a copy orcomplete the Maryland Uniform Consultation ReferralForm, provide member a copy, and fax to JHHC at 410424-4036.
HMO Referral ProcessHealthLINKSubmitting a Referral Log into HealthLINKFrom the office managementmenu selectReferrals/Authorization Select the Specialist tab Enter the patients informationand provider information*(all required fields indicated by abox)
Maryland Uniform Referral FormThe Maryland UniformReferral Form can be faxedto 410-424-4036.
Prior Authorization PriorAuthorization requirements apply uniformly to all Johns HopkinsAdvantage MD products. Submit a request for PriorAuthorization prior to renderingservices by calling:– Medical Management at 844-560-2856– Behavioral Health at 844-340-2217 Submit clinical notes and treatment plan by fax:– Medical Management at 855-704-5296– Behavioral Health at 844-363-6772
Diabetic Supplies Advantage MD members have 0% coinsurance fordiabetic supplies (excluding insulin pumps) Diabetic supplies include:– Blood sugar (glucose) test strips– Blood sugar testing monitors– Lancet devices and lancets– Glucose control solutions
Diabetic Supplies (continued) Advantage MD members will have 0%coinsurance for diabetic supplies (excludinginsulin pumps) In-network providers for diabetic supplies:o DME supplierso Participating network pharmacies For a 2022 listing of participating pharmacies, pleasevisit www.hopkinsmedicare.com
Prescription Drug Benefit (Part D)Formulary Overview Advantage MD offers a comprehensive prescription drugbenefit with coverage in all therapeutic classes,as indicatedby the Medicare Part D rules and regulations.– Drugs excluded by Medicare:drugs used for cosmeticpurposes,erectile dysfunction,cough and cold,vitamins(except prenatal vitamins) and over-the-countermedications. The lists of formulary drugs, coverage limit requirements,and prior authorization forms are available on the plan’swebsite www.hopkinsmedicare.com
Prescription Drug Benefit (Part D)Formulary Overview (continued) Drugs must be used for a“medically accepted indication,”either: Approved by the FDA for the diagnosis or conditionfor which it is being prescribed OR Supported by certain Medicare-recognized referencesNOTE:For more details on prescription drug benefits, please seepharmacy section of theAdvantage MD website.the
Prescription Drug Benefit – Mail Order CVS/caremark, our mail order pharmacy, sends a 3-month supply ofmaintenance medications in one fill, making it easier for the patientby only having to fill four times a year. In addition, a 3-month supply of maintenance medication is availablethrough CVS/caremark mail order at a reduced copay. This means your patient can fill a 90-day supply for only 2 times theretail copay—saving them an equivalent of four retail copays peryear. Doctors and staff can contact CVS/caremark at 877-293-5325(option 2) for PPO or 877-293-4998 (option 2) for HMO, 24 hoursa day, 7 days a week.
Prescription Drug Benefit – Mail OrderThree easy ways for your Advantage MD members to register formail order: Online. Members can information to register on caremark.com. On smartphone or tablet. Download the CVS/caremarkmobile app from the App Store or Google play. By phone. Members can call Customer Service (TTY: 711)number on the back of their Member ID card and select option2. Our Customer Service will get them started with apersonalized registration email or text. The mail order form is available ds/membermail-service-order-form.pdf.
Added Advantages for AdvantageMD Providers Health System/Provider: Care Management support through Johns HopkinsAdvantage MD The Medicare Three-Day Rule for accessing post-acute care doesnot apply to Advantage MD. Members can be admitted to a skillednursing facility (SNF) when it is clinically appropriate.
Care Management Johns Hopkins Advantage MD is committed to becoming the leaderin care management population health solutions. Our care management model promotes prevention skills, performshealth risk identification, and manages member compliance to avoidcostly treatments.We not only outreach to the sickest members tostabilize and manage conditions, we guid
24/7 nurse-advice telephone line Transportation support to medical appointments Medicare Medicare provides Primary Coverage (80%) Medicaid Medicaid pays after Medicare Benefits (20%) Dual Eligibles
