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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 2020
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.
Special Notice- Opioid Prescription Policy Changes
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 Notice
Formulary Change Notice 10 01 20
Formulary Change Notice 07 01 20
Formulary Change Notice 04 20 20
Formulary Change Notice HIV – 12 09 19
Formulary Change Notice Hep C – 12 09 19
Formulary Change Notice – 06 17 19
Formulary Change Notice – 05 29 19
Formulary Change Notice – 04 01 19
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
Unified Opioid 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 Preferred Agents
Update to Criteria – Allowed Length of Treatment for Mavyret
Hepatitis C Treatment Agreement Form
Hepatitis C Treatment Prior Authorization Form – 8.1.2020
Clinical Criteria for Hepatitis C – Effective 1.1.2021
Hepatitis C Sample Treatment Plan – 12.2015
Information related to our Prior Authorization criteria and Utilization Management procedures for our formulary can be found below.
Prior Authorization Criteria
UM Procedures for Formulary
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.
List of NDCs and J-Codes Covered by High Cost Low Volume Risk Mitigation Policy
Drug Name NDC Code J Code (if applicable)
Actimmune 75987011111
Actimmune 42238011112
Cinryze 42227008105 J0598
Novoseven 00169720101
Orfadin 66658020490 J8499
Ravicti 75987005006
Revcovi 57665000201 J3590, J3490
Soliris 25682000101 J1300
Vimizim 68135010001 J1322
Spinraza 64406005801 J2326
Zolgensma see list below * J3590
*Zolgensma NDC List: 71894011001, 71894011501, 71894012002, 71894012103, 71894012203, 71894012303, 71894012404, 71894012504, 71894012604, 71894012705, 71894012805, 71894012905, 71894013006, 71894013106, 71894013307, 71894013407, 71894013507, 71894013608, 71894013708, 71894013808, 71894013909, 71894014009, 71894014109
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 list 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—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.