- Effective 1/1/2020, AIDS/HIV prescription drug benefit coverage will be available under Priority Partners. The PPMCO formulary includes a listing of preferred products in the HIV therapeutic class.
- The Maryland Department of Health (MDH) is responsible for formulary management of drugs used for substance use disorder (SUD) and most drugs used for behavioral health. Please refer to the Maryland Medicaid Mental Health Formulary and the MDH Clinical Criteria for Substance Use Disorders (SUD) Medications for more specific information. This list may also be viewed at the MDH Medicaid Pharmacy Program website.
- Printed copies of the Priority Partners pharmaceutical management procedures and formulary are available to providers, upon request. Please call (888) 819-1043, option 4 to request this information.
- Providers may request a formulary change consideration by completing this Formulary Change Request form.
Prior Authorization, Quantity Limits, & Step Therapy
Prior Authorization
Certain medications require prior authorization, before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. Coverage of these drugs are subject to specific criteria approved by physicians and pharmacists on the Johns Hopkins Health Plans Pharmacy and Therapeutics Committee. Established criteria are based on medical literature, physician expert opinion, and FDA approved labeling information.
How to request prior authorization:
- An electronic prior authorization (ePA) may be submitted using CoverMyMeds ® and Surescripts.
Quantity Limits
Certain prescription medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the Food and Drug Administration FDA, current medical literature and input from a committee of physicians and pharmacists. The three types of quantity limits include the following:
- Coverage limited to one dose per day for drugs that are approved for once daily dosing
- Coverage limited to specific number of units over a defined time frame
- Coverage limited to approve maximum daily dosage
Please refer to the Quantity Limits (QL) in the Pharmacy Formulary.
When medically necessary, an exception to a quantity limit can be requested. If your patient's medical condition warrants the use of a quantity greater than the listed quantity for a drug, you may submit a Pharmacy Quantity Limit Exception Prior Authorization Form to request coverage of a higher quantity. Please follow the above prior authorization steps when requesting a quantity limit exception.
Step Therapy
Certain covered medications are required to satisfy specific step therapy criteria. Step therapy criteria simply means that for certain drug products, members must first have tried one or more prerequisite medications to treat their condition before other medications are covered through their benefit.
Please refer to the Step Therapy (ST) in the Pharmacy Formulary. If your patient’s medical condition precludes the use of prerequisite medications, you may submit a Pharmacy Step Therapy Exception Prior Authorization Form to request a waiving of this requirement. The above prior authorization submission steps are also used to request a step therapy exception.
- Please note that in the event the Priority Partners precertification unit is closed, or a pharmacist cannot contact the prescribing physician, the pharmacist may dispense up to a 96-hour supply of the requested medication to an eligible Priority Partners member.
Retail Pharmacy Network
The pharmacy network includes most chain retailers and independent pharmacies within the State of Maryland, District of Columbia and Delaware. Members may search for a participating network pharmacy. Registration is required for first time use.
For information regarding joining the Priority Partners network, pharmacies may contact CVS Caremark Pharmacy Helpdesk at 1-800-345-5413.
Drug Safety Information
Members may view information on a drug, including how to take the medication, the possible side effects and drug interactions through the pharmacy portal. Log in and select Drug “Reference & Interactions” or select “Medication Safety Alerts” to see the latest drug safety alerts.
Pharmacy Compounded Drugs
To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications when rejected at the pharmacy may require prior authorization. The provider may complete the Compound Prior Authorization Form and fax to the Johns Hopkins Health Plans Pharmacy department at 410-424-4607 for review. The provider must provide clinical documentation to support the request and demonstrate that an FDA approved commercially-available product is not clinically appropriate for the member.
Specialty Medications
Specialty Medications are usually high-cost prescription medications used to treat complex chronic conditions. These drugs typically require special storage and handling, and may not be readily available at a local pharmacy. Specialty medications may also have side effects that require pharmacist and/or provider monitoring. Prior Authorization may be required for most specialty medications. Specialty medications are available through specialty pharmacies, which can provide delivery services to the location of the member's or provider's choice. If a member is unable to receive delivery of medication, specialty medication may be obtained from a retail pharmacy. Members may contact Priority Partners to request obtaining specialty drugs from a retail pharmacy.
Specialty Medications - Pharmacy Benefit: These medications are self-administered and processed through the member’s pharmacy benefit. They are available at a local retail or specialty pharmacy and may require prior authorization. You may find a list of these self-administered specialty medications and their specific authorization requirements on the Priority Partners formulary. See the above steps for requesting prior authorization for self-administered specialty medication.
Specialty Medications – Medical Benefit: These medications are administered by a provider or under supervision of a provider and processed through the member’s medical benefit. Providers may supply these medications and bill the health plan for the medication and related administration using HCPCS Codes or J codes.
View the HCPCS Codes that require prior authorization for medical necessity and site-of-service, and criteria for these medications.
How to request a medical benefit drug prior authorization:
- Submit electronic prior authorization requests through NovoLogix using the Priority Partners Availity secure provider portal. For direction about how to access Novologix through Availity, please refer to the Accessing Novologix Job Aid.
- If Availity is not able to be accessed, please call NovoLogix at 844-345-2803 for assistance, or to obtain a medical injectable prior authorization form.
