Effective January 1, 2021, Quartz Medicare Advantage will begin restricting and requiring prior authorization on several medications when administered by a provider in the clinic or outpatient hospital setting (i.e., medical benefit, Medicare Part B). You can access the full list of medications and their criteria by logging in to My Quartz Tools.
The medications that will begin to require prior authorization include many antineoplastics (pembrolizumab, daratumumab, durvalumab, etc.), biologic DMARDs for dermatological, rheumatological, and gastrointestinal disorders (tocilizumab, certolizumab, vedolizumab, etc.), miscellaneous drugs and biologics (J3490, J3590, etc.) that cost more than $2,500, and others. Additionally, members starting therapy on a medication which has biosimilars available will be required to use the biosimilar version first (infliximab, rituximab, bevacizumab, etc.); members established on therapy will not be required to switch to a biosimilar.
After January 1, 2021, claims for restricted medications will be denied unless a prior authorization request has been submitted and approved by Quartz. If you have a patient who is a Quartz member who is currently receiving a medication that is affected by this change, they will be grandfathered until at least December 31, 2021. After that time, if our criteria have an approval limit, the patient would require a renewed prior authorization approval for Quartz to continue covering the medication.
