Medicare Advantage Members
Prior Authorization Criteria + Part D Drug Formulary
The formulary includes those drugs that are covered under your Quartz Medicare Advantage (HMO) plan if you have chosen Part D coverage.
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 Alternative Drug List 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
FreeStyle Lite, FreeStyle Freedom Lite, FreeStyle Precision Neo, and Precision Xtra are the preferred blood glucose monitoring systems and 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, 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.
In the formulary, you can see which drugs may have special requirements. Special requirements include the following:
Prior authorization. This means you or your doctor 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 doctor may need prior authorization from Quartz before the medication can be covered.
Prior authorization restriction for new starts only. If you are a new member or you have not taken this medication previously, you or your doctor are required to receive approval before Quartz will cover the medication.
Step therapy. This requirement means you must try certain drugs to treat your health condition before Quartz Medicare Advantage will cover the prescribed or requested drug. Please talk with your provider 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.
The drugs on the Quartz Medicare Advantage Formulary are selected with help from the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is a team of health care providers. The formulary is made up of medicines that are 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
- other plan rules are followed
For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC). You can view your plan documents, including the EOC by logging into MyChart.
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 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 on the Part D Drug formulary link above.