Quartz Medicare Advantage Formulary & Criteria

Resources

To view the copay/coinsurance amounts of the different tiers, see the copayment/coinsurance amounts tables.

For details on how to request approval of a non-formulary medication or a tiering exception, see the Exceptions to the Formulary page.

Refer to our top drug categories to see our alternative or preferred drugs for the most common drugs that are not covered or are in a non-preferred tier.

Preferred blood glucose meters and test strips

The OneTouch® product line are the preferred blood glucose meters and test strips. This includes the OneTouch Verio Reflect®, OneTouch Verio Flex®, OneTouch Ultra Plus Flex™, OneTouch Ultra 2® meters and their associated test strips. Test strips are limited to 200 strips per 30 days. Unless an exception request is approved, other meters, test strips, and quantities are not covered.

Preferred continuous glucose monitors (CGMs)

FreeStyle Libre 14-day, FreeStyle Libre 2, FreeStyle Libre 3, Dexcom G6, and Dexcom G7 are the preferred continuous glucose monitors when submitted through the pharmacy benefit manager (PBM). Prior authorization is not required if the member has had a paid claim for insulin through the PBM in the past six months. Members that have not had a paid claim for insulin through the PBM in the past six months will require prior authorization for coverage.

Formulary & criteria changes

• Formulary & criteria changes effective December 31, 2023

Special requirements

In the formulary, you can see which drugs may have special requirements. Special requirements include the following:

Prior authorization. This means you or your patient are required to get approval before Quartz will cover the medication.

Prior authorization for Part B vs. Part D determination. This means a medication may be covered under Medicare Part B or Part D, but you or your patient may need prior authorization from Quartz before the medication can be covered.

Prior authorization restriction for new starts only. If your patient is a new member or has not taken this medication previously, you or your patient are required to receive approval before Quartz will cover the medication.

Step therapy. This requirement means your patient must try certain drugs to treat their health condition before Quartz Medicare Advantage will cover the prescribed or requested drug. Please talk with your patient about this process.

Quantity limits. This means there is a limit on the amount of the drug that is covered per prescription fill or within a specific time frame.

Pharmacy & Therapeutics (P&T) Committee

These drugs are selected by Quartz Medicare Advantage in consultation with the Pharmacy and Therapeutics (P&T) Committee, a team of health care providers. This list represents the prescription therapies believed to be a necessary part of a quality treatment program. Quartz Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Quartz Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC).

Brand and generic drugs

Quartz Medicare Advantage covers both brand-name drugs and generic drugs within the Formulary. Generic drugs have the same active ingredient formula as a brand-name drugs. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

Updating the formulary

Formulary development and maintenance is an ongoing process. The P&T Committee regularly reviews new and existing medications to ensure the formulary remains responsive to the needs of our members and providers. The formulary is updated periodically and changes are able to be seen by clicking the links for the online searchable or printed formulary above.

Exceptions to the formulary

The formulary is a list of medications that are covered by Quartz Medicare Advantage (HMO). If you are taking a medication that is not on the formulary, your doctor can ask for an exception to the formulary.

Exceptions include:

• The drug is not covered by the plan (Non-formulary).
• The drug is covered, but there are restrictions on the drug. For example,
  • You need to try drug A to see if it will work before drug B can be covered (step therapy), or
  • There are limits on the number of tablets covered per day (quantity limit).
• The drug you take is covered, but it is in a non-preferred cost-sharing tier (tier exception)

If your doctor believes you have medical reasons for an exception, he or she can help you request an exception. They may submit a Request for Medicare Prescription Drug Coverage Determination.

Common tier exception requests include:

• Tier 4 (Non-preferred drugs). If your medication is a brand name drug, your doctor can ask us to cover it at the lower copay cost of other drugs in Tier 3 (preferred brand).
• Tier 4 (Non-preferred drugs) If your medication is a generic drug, your doctor can ask us to cover it at the copay cost of lower-tiered alternative formulary drugs.
• Tier 2 (generic), your doctor can ask us to cover it at the lower copay cost of other alternatives in Tier 1 (if applicable).

Tier exceptions are not allowed for:

• Brand drugs to be covered at generic tiers
• Specialty drugs (tier 5) are not eligible for tier exception

What to do if your drug is not on the formulary:

• Change to another drug. Ask your doctor to see if another drug on the Quartz Medicare Advantage formulary might work just as well for you.
• Submit a Request for Medicare Prescription Drug Coverage Determination. Your doctor can ask for an exception so we will cover a non-formulary drug due to medical reasons. Such reasons include: – all of the similar drugs on the formulary would not be effective for you or -they would cause side effects for you.
• If Quartz Medicare Advantage approves your exception, it will be covered at a Tier 4 (non-preferred drug) copay.