2025 Pharmacy Coverage
Aurora Health Quartz Medicare Advantage
Understanding what Quartz covers and what you'll pay for drugs
Quartz Medicare Advantage (HMO) offers several plan options with prescription drug benefits (Rx) coverage. These plans cover Part D drugs and Part B drugs.
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2025 prescription drug coverage
Quartz Medicare Advantage has a list of all covered drugs (formulary) that you can view in a printable document. 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.
There is a deductible for Tiers 3, 4 and 5 prescription drugs. Core D $325; Value D $300; Elite D $275.
You pay the following until your True Out-of-Pocket (TrOOP) costs reach $2,000. The TrOOP is the maximum you will spend out of pocket. You may get your drugs from network retail or mail-order pharmacies.
Retail 30-day |
Retail 60-day |
Retail 90 to 100-day |
Mail Order 90 to 100-day |
|
|---|---|---|---|---|
|
Tier 1 (Preferred Generic) |
$0 |
$0 |
$0 |
$0 |
|
Tier 2 (Generic) |
$5 |
$10 |
$12.50 |
$12.50 |
|
Tier 3 (Preferred brand)* |
25% after deductible |
25% after deductible |
25% after deductible |
25% after deductible |
|
Tier 4 (Non-preferred drugs) |
33% after deductible |
33% after deductible |
33% after deductible |
33% after deductible |
|
Tier 5 (Specialty tier) |
29% of cost |
Not offered |
Not offered |
Not offered |
|
Tier 6 (Select Care drugs) |
$0 |
$0 |
$0 |
$0 |
*Tier contains many common brand name drugs and some higher-cost generic drugs and insulin.
Note: Our plan covers Part D vaccines (e.g., Tetanus (Tdap), shingles, etc.) at no extra cost, even if your plan has a deductible and you haven’t paid it. There is no extra cost for vaccines received in a pharmacy. You will need to submit a reimbursement form for vaccines received in a clinic.
Helpful resources for your pharmacy and prescription needs
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 Coverage Determination Request.
Common Tier Exception Requests include:
- Tier 4 (Non-Preferred Drugs) your doctor can ask us to cover it at the lower copay cost applicable to formulary alternatives in a lower cost-sharing tier (if applicable).
- Tier 2 (Generic), your doctor can ask us to cover it at the lower copay cost applicable to formulary alternatives in Tier 1 (if applicable).
Tier Exceptions are not allowed for:
- Brand Drugs to be covered at Generic tiers (unless there is a brand drug covered at that tier).
- Brand or Generic Drugs when there are no formulary alternatives covered at a lower tier.
- Specialty drugs (Tier 5) are not eligible for a 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 formulary exception request. 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.
If you are a current member and a drug you are taking will be removed from the Formulary or restricted in some way for next year, we will allow you to request an exception in advance for the next year. We will give you an answer to your request for an exception before the change takes effect.
Low-Income Subsidy
Medicare offers a number of ways to help low income members pay for their medicine. If you have Medicare and limited income and resources, you may qualify for extra help paying for your prescription drugs.
Help with Medicare Prescription Drug Costs
If you qualify, you will not pay as much for your medications.
For more information:
- Visit the Extra Help website (By clicking on this link, you will leave the Quartz Medicare Advantage website)
- Call Social Security at (800) 772-1213 (for the hearing impaired, TTY (800) 325-0778)
If you have the necessary documentation, we can help fix your eligibility issues. Contact a Quartz Champion for help.
Where can I get information about Best Available Evidence (BAE)? How does the CMS website help you?
You can visit the CMS website. (By clicking on this link, you will leave the Quartz Medicare Advantage website).
If you are a Quartz Medicare Advantage member that qualifies for Part D Low Income Subsidy, please refer to the information below.
2025 Core D
If your level of Extra Help is 100%, your premium is $0.00.
2025 Elite D
If your level of Extra Help is 100%, your premium is $23.50.
2025 Value D
If your level of Extra Help is 100%, your premium is $0.00.
Have you qualified for Extra Help but are still paying a full copayment for your medicine?
If you believe you are paying an incorrect drug copayment and you have qualified for Extra Help, Quartz Medicare Advantage can help confirm your eligibility.*
We can help you if you have ONE of following documents:
- A copy of the beneficiary’s Medicaid card (including the beneficiary’s name and eligibility date)
- A copy of a state document that confirms active Medicaid status
- A printout from the state electronic enrollment file showing Medicaid status
- A screen print from the state’s Medicaid system showing Medicaid status
- Other documentation provided by the state showing Medicaid status
- A letter from the Social Security Administration (SSA) showing that the individual receives Supplemental Security Income (SSI)
- An Important Information letter from SSA confirming that the beneficiary is “automatically eligible for extra help”
For Institutionalized Members
Institutionalized members may have a zero cost-sharing level. In order for the member to get that benefit, Quartz Medicare Advantage must provide Medicare ONE or more of the following documents:
- A remittance from the care facility (institution); the remittance must show a Medicaid payment for a full calendar month
- A copy of a state document that confirms Medicaid payment to the care facility on behalf of the member for a full calendar month
- A screen print from the state’s Medicaid system showing the member’s institutional status, based on at least a full calendar month’s stay for Medicaid payment purposes
*Quartz Medicare Advantage follows Medicare’s Best Available Evidence Policy. (By clicking on this link, you will leave the Quartz Medicare Advantage website.)
Transition Fills
What happens if a drug you take is not on the Formulary (drug list) or is listed as restricted in some way (such as needing Prior Authorization)?
You may be able to get a temporary supply of the drug if you qualify.
This temporary supply is called a transition fill. This allows you to continue taking your medication without interruption. When you start your transition fill, you will receive a letter from Quartz that explains it’s a temporary supply. The prescriber will also receive a copy of this letter. Having a transition fill gives you time to talk to your doctor. You and your doctor need to decide what to do when your temporary supply runs out. There may be a different drug that is covered by the plan that might work just as well for you which may cost less. Otherwise, you or your doctor can ask Quartz Medicare Advantage to cover the medication that you are currently taking. A Request for Medicare Prescription Drug Coverage Determination may be submitted to start this process.
If you have questions, please contact a Quartz Champion. You may also call through a video relay service company of your choice. Interpreter services are provided free of charge to you.
For more information, you can review the Quartz Medicare Advantage Part D Drug Transition policy.
To be eligible for a transition fill, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following:
- The drug you have been taking is no longer on the plan’s Formulary (drug list)
- The drug you have been taking is now restricted in some way
2. You must be in one of the situations described below:
- For those members who are new to the plan and are not in a long-term care facility – We will cover a temporary supply of your drug one time only during the first 108 days of your membership in the plan. This temporary supply will be for a maximum of 30-day supply, or less if your prescription is written for fewer days.
- For those who are new members and are residents in a long-term care facility – We will cover a temporary supply of your drug during the first 108 days of your membership in the plan. The first supply will be for a maximum of 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 108 days in the plan.
- For those who have been a member of the plan for more than 108 days and are a resident of a long-term care facility and need a supply right away – We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you.
Contact us
Quartz is here to help. That’s why we make it easy to reach us.
Call Quartz Customer Success (844) 644-3455 or message us on Quartz MyChart.