Drugs may fall into the following categories –
View Gundersen Health Plan's Prescription Drug Formulary –
View the complete list in our up-to-date Formulary. This list does not include your costs for the drugs.
The amount you pay for your medication(s) can be located in your Plan's Summary of Benefits.
The Quartz Pharmacy & Therapeutics (P&T) Committee creates and updates the prescription drug formulary. This committee is made up of doctors and pharmacists who care for Quartz members. The P&T Committee meets every month to review medications. They decide the formulary status and restriction status of each medication.
A variety of factors are considered. They include safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form, appropriate uses and cost-effectiveness. In making formulary decisions, the committee uses the most up-to-date information on the medication from a variety of sources. These include published clinical trials, data submitted to the Food and Drug Administration (FDA) for drug approval and recommendations from local or national treatment guidelines. Additionally, the committee asks for information from local health care practitioners who are experts in the use of the drug class under review.
The Formulary is updated monthly.
Most changes involve adding new drugs or drugs that are newly available in generic form. At times, drugs are removed from the formulary or moved to restricted status. Check the website or request an up-to-date version from Quartz Customer Service.
When new, patented drugs enter the market, they are called brand drugs. These branded drugs are protected by patents that last up to 17 years. They are usually more expensive. After the patent expires, other companies can make drugs with the same active ingredients. These drugs are called generics, and they are usually cheaper. The first version of a medication on the market is usually called “the brand.” An example is Prozac, which is another name for the drug fluoxetine.
After the Prozac patent expired, other companies are marketing versions of the medication. These versions are called “generics.” Determining brand / generic status is not always easy. The P&T committee uses a national database of medication-related information called the First Data Bank National Drug Data File. The brand or generic status of a medication as listed in First Data Bank determines whether that medication is considered a generic or a brand on the Drug Formulary.
Yes, according to the Federal Food and Drug Administration (FDA) generic drugs are safe and effective. Generic medications must meet the same standards for purity, strength, and quality as brand name drugs. They must be approved by the FDA before they can be sold to consumers.
Generics may look different from the brand name medication in color, shape, or size as required by the Federal Food and Drug Administration (FDA). For more information visit the FDA’s Office of Generic Drugs.
If you are interested in switching to a generic, you may talk with your pharmacist and / or provider to find out if a generic equivalent is available in the drug(s) you current take, and to determine if a generic is right for you.
A drug changes from preferred to non-preferred
If your drug changes from preferred to non-preferred, your coverage continues at a Tier 3 copay.
In other words, your copay will be higher, but you will not pay the full cost of the drug.
If you want to keep your copay at the same level, ask your doctor to find a similar formulary drug.
If you have had a recent claim for the medication as a Quartz member, you and your practitioner will receive a notification of the formulary change and your options BEFORE the change occurs. You will be given sufficient time to discuss your options with your practitioner and make a decision.
You generally have two options –
A drug changes to restricted status
If you are taking a drug that becomes restricted, your coverage may change in one of two ways.
The change is based on the type of drug and the nature of the disease it treats. You will continue to receive coverage for the drug from Quartz. This happens when the P&T Committee believes that it is not safe to stop taking the medication. Another reason is that sometimes switching to another medication is complex and difficult. In either case, your coverage for the drug will continue without the need for Prior Authorization.
Only patients who are new to the drug after it becomes restricted need Prior Authorization to receive coverage. Coverage for the newly restricted drug will end and a different medication will be suggested. You and your doctor will be notified before the restriction occurs. You will both be given information about similar drugs that are not restricted.
In general, you have three choices to review with your doctor:
Before your doctor writes a prescription, tell your doctor that you prefer generic or formulary drugs if possible.
That will help the doctor find the drugs with the lowest copay.
If your doctor gives you drug samples to start treatment, it’s best to find out if that specific drug is on the formulary. Starting with samples does not mean that the drug will be covered or have the lowest possible copay.
First, covering just one month of medication reduces waste. Drugs are often switched or the dosage changes. Even medications that you have been taking for a long time may unexpectedly change. Proper disposal of unused drugs is difficult, so it’s best to have less to throw away.
Second, Quartz wants to keep costs down for active members. A one-month supply doesn’t allow stockpiling of medication by those who are planning to end their membership. If the medication you take is considered a chronic medication, it may qualify for the Choice90 program.
When purchasing prescription medications, you are encouraged to use your Pharmacy Prescription Card.
If for some reason you are unable to utilize your pharmacy card, and are required by the pharmacy to pay for the medications, you may submit your itemized pharmacy receipt to us.
Prescription medications purchased from a participating or non-participating pharmacy will be reimbursed through our Pharmacy Benefits Management (PBM) at our current discount contracted rates. Any difference between the discount contracted rate and what the provider has billed will be your responsibility.
Ancillary charges refer to the difference in cost between a brand and generic medication. Ancillary charges may apply whenever a member or provider chooses a brand name medication when a generic equivalent is available.