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Johns Hopkins Bayview Medical Center PPO Plan — 2023

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In-Network Retail Pharmacy (30-day supply)In-Network Retail Pharmacy (90-day supply)Mail Order (90-day supply)
Oral Contraceptives
Generic$0$0$0
Preferred$40$120$80
Non-Preferred$65$195$130
Prescription Drugs
Generic$10$30$20
Preferred$40$120$80
Non-Preferred$65$195$130
Brand with Generic Equivalent$65 plus the cost differential between generic and brand$195 plus the cost differential between generic and brand$130 plus the cost differential between generic and brand
Specialty MedicationsRefer to Preferred/Non-Preferred BrandRestricted to a 30-day retail supply onlyRestricted to a 30-day retail supply only
Revised
October 12, 2022
Group Number
E00006, E00007, E00161
Plan Codes
Under $50K: JP1; $50K to $120K: JP3; $120K and over: JP5
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