Pharmacy Frequently Asked Questions

Answer:

The drug formulary is a list of safe, effective, and cost-effective drugs. These drugs are eligible for coverage.

Not all prescription drugs are covered, so make sure to check the formulary when you receive a prescription.

Drugs may fall into the following categories:

• Excluded: Some drugs or groups of drugs are not covered under your prescription drug benefit. These are called excluded medications.

Examples include:

• drugs to treat hair loss
• drugs to treat sexual dysfunction
• drugs for cosmetic use

Over-the-counter (OTC) medications may be excluded. Excluded drugs are not listed on the Quartz prescription drug formulary. Your specific benefit exclusions are listed in the Exclusions section of your Prescription Drug Benefit Rider.

About the Formulary

View Quartz’s Prescription Drug Formulary two ways:

View the complete list in our up-to-date formulary. This list does not include your costs for the drugs.

Login to MyChart and view the Online Pharmacy Benefit Tool.

• Restricted: Restricted drugs need Prior Authorization before you can get coverage. Restricted drugs may be preferred or non-preferred. You can find which drugs are restricted in the Drug Formulary.
• Non-preferred drugs: Some Quartz plans cover non-preferred drugs. Most often, these drugs have higher copays or you pay the coinsurance amount. Read your Quartz Prescription Drug Benefit Rider to find out if need Prior Authorization for non-preferred drugs. Non-preferred drugs typically have less clinical value and have therapeutic alternatives in covered medications.
• Non-formulary drugs: Non-formulary drugs are not covered by your prescription drug benefit. However, you may request a medical exception. Quartz will then review your request based on your unique situation.

Some drugs are covered only at certain times. Check your Prescription Drug Benefit Rider for full information.

Answer:

Some drugs you get filled at the pharmacy may require prior approval from Quartz before they are covered. This process is called Prior Authorization (PA).

To see which pharmacy benefit drugs need prior authorization, check your formulary. If, after checking your formulary, you find that your drug needs a PA, your provider can submit a prior authorization form by faxing it to the number located on the form.

Does your doctor or nurse give you your medicine (through an IV, for example)?

If so, you may need an approved prior authorization first. Be sure to check the clinic administration medication list. If your medication is on the list, talk to your provider and ask that they submit a clinic-administered medication prior authorization request form for you. Your provider will ensure we have the necessary medical history information to review the request as quickly as possible.

If the request is URGENT, your provider must:

• Provide clinical documentation
• Describe why the request is urgent
• Sign the form

We will only treat requests as urgent for documented clinical reasons. Otherwise, we will process the request within our normal time frame.

What form does my provider need to fill out to request a PA?

There are two PA forms. One is for pharmacy benefits, and one is for medical benefits. Once the medication PA request form is filled out, the pharmacy benefits form will be securely sent to Optum Rx and the medical benefit will be securely sent to Quartz.

Processing Medication PA Requests

Once the medication PA request form is received, a decision is made as soon as possible. However, if information is missing or there are additional to ask questions, it can take up to 15 days.

Once a decision is made, a notice will be sent to you and your doctor.

Answer:

How is the Formulary developed?

The Quartz Pharmacy & Therapeutics (P&T) Committee creates and updates the prescription drug formulary. This committee is made up of doctors and pharmacists who care for Quartz members. The P&T Committee meets every month to review medications. They decide the formulary status and restriction status of each medication.

A variety of factors are considered. These include safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form, appropriate uses, and cost-effectiveness. In making formulary decisions, the committee uses the most up-to-date information on the medication from a variety of sources. These include published clinical trials, data submitted to the Food and Drug Administration (FDA) for drug approval, and recommendations from local or national treatment guidelines. Additionally, the committee asks for information from local health care practitioners who are experts in the use of the drug class under review.

The formulary is updated monthly.

Most changes involve adding new drugs or drugs that are newly available in generic form. At times, drugs are removed from the formulary or moved to restricted status. Check the website or request an up-to-date version from Quartz Customer Service.

Quarterly updates are listed on the formulary page for each specific formulary on the website.

Answer:

How are drugs classified as generic or brand?

When new, patented drugs enter the market, they are called brand drugs. These branded drugs are protected by patents that last up to 17 years. They are usually more expensive. After the patent expires, other companies can make drugs with the same active ingredients. These drugs are called generics, and they are usually cheaper. The first version of a medication on the market is usually called “the brand.” An example is Prozac, which is another name for the drug fluoxetine. 

After the Prozac patent expired, other companies began marketing versions of the medication. These versions are called “generics.” Determining brand/generic status is not always easy. The P&T committee uses a national database of medication-related information called the First Data Bank National Drug Data File. The brand or generic status of a medication as listed in First Data Bank determines whether that medication is considered a generic or a brand on the drug formulary.

Answer:

Are generic drugs safe and/or effective?

Yes, according to the Federal Food and Drug Administration (FDA) generic drugs are safe and effective. Generic medications must meet the same standards for purity, strength, and quality as brand-name drugs. They must be approved by the FDA before they can be sold to consumers.

Generics may look different from the brand name medication in color, shape, or size as required by the FDA. For more information, visit the FDA’s Office of Generic Drugs.

If you are interested in switching to a generic, you may talk with your pharmacist and/or provider to find out if a generic equivalent is available for the drug(s) you currently take and to determine if a generic is right for you.

Answer:

A drug changes from preferred to non-preferred

If your drug changes from preferred to non-preferred, your coverage continues at a Tier 3 copay.

In other words, your copay will be higher, but you will not pay the full cost of the drug.

If you want to keep your copay at the same level, ask your doctor to find a similar formulary drug.

If you have had a recent claim for the medication as a Quartz member, you and your practitioner will receive a notification of the formulary change and the options available to you BEFORE the change occurs. You will be given sufficient time to discuss your options with your practitioner and make a decision.

You generally have two options:

• Continue taking the drug at the Tier 3 copay level
• Switch to an appropriate preferred version of the medication to receive coverage at the preferred copay level

A drug changes to restricted status

If you are taking a drug that becomes restricted, your coverage may change in one of two ways.

The change is based on the type of drug and the nature of the disease it treats. You will continue to receive coverage for the drug from Quartz. This happens when the P&T Committee believes that it is not safe to stop taking the medication. Another reason is that sometimes switching to another medication is complex and difficult. In either case, your coverage for the drug will continue without the need for Prior Authorization.

Only patients who are new to the drug after it becomes restricted need Prior Authorization to receive coverage. Coverage for the newly restricted drug will end and a different medication will be suggested. You and your doctor will be notified before the restriction occurs. You will both be given information about similar drugs that are not restricted.

In general, you have three choices to review with your doctor:

1. Switch to a similar formulary drug that does not require Prior Authorization. This drug will be covered at the formulary copay level
2. Ask your doctor to request Prior Authorization for continued coverage of the restricted drug.
3. Continue taking the restricted drug without coverage (you pay the full cost).

Answer:

How do I make sure the medicine my doctor gives me is at the lowest copay?

Before your doctor writes a prescription, tell your doctor that you prefer generic or formulary drugs, if possible.

That will help the doctor find the drugs with the lowest copay.

If your doctor gives you drug samples to start treatment, it’s best to find out if that specific drug is on the formulary. Starting with samples does not mean that the drug will be covered or have the lowest possible copay.

You can also check the price you would pay for any medication by using the online Pharmacy Benefit Tool within MyChart.

Why does Quartz only pay for a one-month supply of medication at a time?

First, limiting coverage to one month reduces waste that occurs when a medication is switched or the dosage changes. Even medications that you have been taking for a long time may unexpectedly change. Proper disposal of unused drugs is difficult, so it’s best to have less to throw away.

Second, Quartz wants to keep costs down for active members. A one-month supply doesn’t allow stockpiling of medication by those who are planning to end their membership. If the medication you take is considered a maintenance medication, it may qualify for the Choice90 program.

Answer:

How do I request reimbursement for a prescription I paid for myself?

For Quartz claims, please fill out (or have your pharmacist fill out) the Direct Member Reimbursement Form. Be sure to include all receipts. Prescription medications will be reimbursed through Quartz Pharmacy Benefits Management (PBM) at our current discount contracted rates. Any difference between the discount contracted rate and what the pharmacy or health care provider has billed will be your responsibility.

Answer:

What is my copay if the medication is in a box that lasts more than 30 days?

Some maintenance medications such as insulin pens and inhalers are packaged in a box that is not easily broken into a 30-day supply. These are considered “unbreakable packages.” Quartz allows the pharmacy to submit the correct days’ supply based upon your prescribed dose (e.g., one copay for prescriptions that last one to 30 days, two copays for prescriptions that last 31-60 days, and three copays for prescriptions that last 61-90 days).

Answer:

Members traveling outside of the United States may be covered for up to an additional 90-day travel supply of medications. To activate this benefit, contact Optum Rx at (800) 496-7509 and let them know where you are traveling and your travel dates. Your coverage will include an additional 90 days supply in addition to your current 30 day supply of medication. That is a maximum of 120 days of medication for you to have on hand while you travel. You will be responsible for your usual copays or coinsurance.

If you need medication for more than 120 days, you will be responsible for 100% of the cost of the medication for the supply above 120 days. Upon return from travel complete a direct member reimbursement form and send it to Optum Rx. To be reimbursed, members must maintain continuous Quartz prescription coverage during travel and have active Quartz coverage upon return. Requests for reimbursement for members who do not maintain continuous Quartz coverage will be denied for exceeding their benefit.