Pharmacy - Jai Medical Systems Managed Care Organization

The Jai Medical Systems Managed Care Organization Formulary is available online through Formulary Navigator.

Access to the formulary is free and is available at https://client.formularynavigator.com/Search.aspx?siteCode=9386334079. The formulary can also be found below:

Jai Medical Systems Formulary 2024
New: CY2020 HIV/AIDS Medication Formulary

Requests for a print edition of Jai Medical Systems’ Formulary can be made to our Customer Service Department at 1-888-JAI-1999.

Opioid Limitations Policy
Referral Resource: Beacon Health Options Maryland
In partnership with our HealthChoice managed care organizations, Maryland Medicaid’s Opioid Drug Utilization Review Work group is hosting provider training sessions on Medicaid’s new opioid prescription policy. Providers need only attend one session, but session space is limited.
More Information
DHMH and MCO Notice regarding Opioid Policy Changes
Notice to Prescribers regarding Jai Medical Systems’ Opioid Prescription Policy
Opioid PA QLL Chart

Formulary Change Notices

Pharmacy Resources

Searchable Preferred Drug List including generic availability
Find an In-Network Pharmacy

Prescription Prior Authorization

Providers interested in completing a Prescription Prior Authorization may download a form here. Members who need to request an exception for a medication that is not covered on the formulary may also download the form below for their provider to fill out and submit.
Prescription Prior Authorization Form – As of 04/2024
Unified Opioid Prior Authorization Form

Prior Authorization for Hepatitis C Therapy will require completion of the Hepatitis C Treatment Prior Authorization Form below. For your convenience, we have also posted the Hepatitis C clinical criteria below.
Hepatitis C Preferred Agents
Update to Criteria – Allowed Length of Treatment for Mavyret
Hepatitis C Treatment Agreement Form
Hepatitis C Treatment Prior Authorization Form 01.01.2024
HCV Clinical Criteria effective 09.22.22
Hepatitis C Sample Treatment Plan 06.2022

Information related to our Prior Authorization criteria and Utilization Management procedures for our formulary can be found below.
Prior Authorization Guidelines
UM Procedures for Formulary

Special Notice – Gender Affirming Care
Gender Affirming Care Services Updates 12.2023
Gender Affirming Care Medical Necessity Provider Attestation

Special Notice – High Cost, Low Volume Drugs

In accordance with the Maryland Department of Health’s High Cost, Low Volume Drug Risk Mitigation Policy and the Social Security Act 1927 (d)(5), Jai Medical Systems will not pay for any of the aforementioned high-cost drugs that are not appropriately pre-certified by Jai Medical Systems.

High-Cost, Low Volume (HCLV) Drugs Covered by HCLV Mitigation Policy

Our health plan will not conduct any retrospective review for these drugs; they must be pre-certified and approved by our plan beforehand. Please be advised that this policy includes both Physician Administered Drugs and retail pharmacy drugs. Please be advised that this policy is subject to change. If you are unsure of whether or not a medication requires prior authorization and/or pre-certification, please contact our Utilization Management Department at 1-888-JAI-1999.

Special Notice: Opioid Prescription Changes 2023

Special Notice—Asthma Controller Medications

To aid in patient compliance and effectiveness of treatment, Jai Medical Systems is increasing the allowed days’ supply rule for certain asthma controller medications. If your patient is on a formulary asthma controller medication, you may now write for up to a 90-day supply. You may also give the patient up to 3 refills. This is true for formulary medications, with or without a prior authorization.

If your patient is on a non-formulary medication that has been approved based on medical necessity, they too may receive up to a 90-day supply. New authorizations for medical necessity will be required, as appropriate.