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Part D Formulary & Criteria


NOTE: FreeStyle Lite, FreeStyle Freedom Lite, FreeStyle Precision Neo, FreeStyle InsuLinx, and Precision Xtra These are the preferred blood glucose monitoring systems and test strips. Other test strips and meters are not covered as of 1/1/2021 (unless an exception request is approved). Test strips are limited to 200 strips per 30 days (unless exception request is approved).

Continuous Glucose Monitors (CGMs) covered at the pharmacy: Therapeutic CGMs (Freestyle Libre, FreeStyle Libre 2, and Dexcom G6) are covered at participating pharmacies with an approved prior authorization. Prior authorization criteria are listed here.

Special Requirements

Within the Formulary, you will see which drugs may have special requirements, including:

  • Prior Authorization – You or your physician are required to get approval before you can fill a prescription for the drug.
  • Step Therapy – You are required to try certain drugs to treat your health condition before Quartz Medicare Advantage will cover another drug for that condition.
  • Quantity Limits – There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.

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 drug. 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 on the Part D Drug Formulary link above. 

This webpage was updated on January 27, 2021.