Exceptions to the Formulary
The formulary is a list of medications that are covered by Quartz Medicare Advantage (HMO). If you are taking a medication that is not on the formulary, your doctor can ask for an exception to the formulary.
Exceptions include –
- The drug is not covered by the plan (Non-Formulary).
- The drug is covered, but there are restrictions on the drug. For example,
- You need to try Drug A to see if it will work before Drug B can be covered (Step Therapy), or
- There are limits on the number of tablets covered per day (Quantity Limit).
- The drug you take is covered, but it is in a non-preferred cost-sharing tier (Tier Exception)
If your doctor believes you have medical reasons for an exception, he or she can help you request an exception. They may submit a Coverage Determination Request.