The Jai Medical Systems Managed Care Organization Formulary is available online through Epocrates.
Registration is free and is available at www.epocrates.com. The formulary can also be found below.
Requests for a print edition of Jai Medical Systems’ Formulary can be made to our Customer Service Department at 1-888-JAI-1999.
Special Notice- Opioid Prescription Policy Changes
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.
Formulary Change Notice
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
Analgesic Opioid Prior Authorization Form
Fentanyl Prior Authorization Form
Prior Authorization for Hepatitis C Therapy will require completion of the forms below. For your convenience, we have also posted the Hepatitis C clinical criteria below.
Hepatitis C Treatment Agreement Form
Clinical Criteria for Hepatitis C – 9.2016
Hepatitis C Prior Authorization Form – 7.2015
Hepatitis C Sample Treatment Plan – 12.2015
Hepatitis C Enhanced Treatment Plan – 12.2015 *Enhanced Treatment Plan is required for all re-treatment requests.
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.