Menu

Medicare Advantage Members

Gundersen Prior Authorization Criteria + Part D Formulary

The formulary includes those drugs that are covered under your Quartz Medicare Advantage (HMO) plan if you have chosen Part D coverage.

Resources

Coverage Determination Form

Online Searchable Formulary – 2022 | 2023

Printed Formulary – 2022 | 2023

Part B Medications Requiring Prior Authorization

Prior Authorization Criteria (Part B)

Prior Authorization Criteria (Part D) – 2022 | 2023

Step Therapy Criteria (Part D) – 2022 | 2023

For the copay amounts of the different tiers, see the Copayment Amounts for 2022 or the Copayment Amounts for 2023.

For details on how to request approval of a non-formulary medication or a tiering exception, see the Exception Requests page.

For a list of the most common drugs that are either not covered or are in a non-preferred tier and their alternative covered or preferred drug, see our 2022 Alternative Drug List. or our 2023 Alternative Drug List.

NOTE: FreeStyle Lite, FreeStyle Freedom Lite, FreeStyle Precision Neo, and Precision Xtra are the preferred blood glucose monitoring systems and test strips. Other test strips and meters are not covered (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: CGMs (Freestyle Libre 14 Day, FreeStyle Libre 2, and Dexcom G6) are covered at participating retail pharmacies with approved prior authorization. Prior authorization criteria are listed here.

Formulary & Criteria Changes

Formulary & Criteria Changes Since December 31, 2021

Special Requirements

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

Prior Authorization – Some medications need approval by the Pharmacy Department before Quartz Medicare Advantage will cover them.

Step Therapy – some prescription drugs require Step Therapy. Step Therapy means that you have to try one or more drugs first before Quartz Medicare Advantage will cover the prescribed drug.

Quantity Limits – Some prescriptions have limits on how much of the medicine covered per prescription. It can also mean that you can only get a specific amount of the drug within a period of time.

P&T Committee

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 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.

Medicare Advantage Drug Information

Looking for information on your drug plan? Find answers to your questions and view the drug list.