Have questions about your Drug Coverage? 

If you have Quartz' pharmacy benefit, here are answers to the most frequently asked questions.

What is a drug formulary?

The Drug Formulary is a list of safe, effective and cost-effective drugs. These drugs are eligible for coverage.

Not all prescription drugs are covered so make sure to check the formulary when you receive a prescription.

Drugs may fall into the following categories –

  • Excluded: Some drugs or groups of drugs are not covered under your prescription drug benefit. These are called excluded medications.
    Examples include:
    • drugs to treat hair loss,
    • sexual dysfunction or
    • drugs for cosmetic use.
    Over-the-counter (OTC) medications may be excluded. Excluded drugs are not listed on the Quartz Prescription Drug formulary. Your specific benefit exclusions are listed in the Exclusions section of your Prescription Drug Benefit Rider.

About the Formulary

View Quartz’s Prescription Drug Formulary two ways –

View the complete list in our up-to-date Formulary. This list does not include your costs for the drugs.

Login to MyChart and view the Online Pharmacy Benefit Tool.

 

  • Restricted: Restricted drugs need Prior Authorization before you can get coverage. Restricted drugs may be preferred or non-preferred. You can find which drugs are restricted in the Drug Formulary.
  • Non-preferred drugs: Some Quartz plans cover non-preferred drugs. Most often, these drugs have higher copays or you pay the coinsurance amount. Read your Quartz Prescription Drug Benefit Rider to find out if need prior authorization for non-preferred drugs. Non-preferred drugs typically have less clinical value, and have therapeutic alternatives in covered medications.
  • Non-formulary drugs: Non-formulary drugs are not covered by your prescription drug benefit. However, you may request a medical exception. Quartz will then review your request based on your unique situation.
  • Some drugs are covered only at certain times. Check your Prescription Drug Benefit Rider for full information.
What is Medication Prior Authorization?

Some drugs must be approved by Quartz before they are covered.
This process is called Prior Authorization.

To see which drugs need Medication Prior Authorization, check your formulary.

You can also see the Medication Prior Authorization List.

Does your doctor or nurse give you your medicine (through an IV, for example)?

If so, you may need an approved Prior Authorization first. Be sure to check the Medication Prior Authorization List. If the medicine is on that list, you need to get a Medication Prior Authorization.

Your clinic staff can help you.

How do I get a Medication Prior Authorization (PA)?

You or your doctor can fill out a Medication Prior Authorization Request (PA Request). Or your designated representative can fill it out. You can send it in via the web, fax, mail, or telephone.

It makes the most sense to have your doctor / nurse or pharmacist fill out the PA Request for you. They will have your medical history information that is needed. That means the PA Request can be reviewed more quickly.

Once the Medication PA Request Form is filled out, it has to be sent to Quartz in a secure way.

Secure Online Medication PA Request Form

Print Medication PA Request Form
(Fax using a secure fax number).

Once Quartz gets the Medication PA Form, we make a decision as soon as possible. However, if we don’t have all the information and have to ask questions, it can take up to 15 days.

Once a decision is made, we will send a notice to you and your doctor.

If the request is URGENT, the request must:

  • Provide clinical documentation from the prescriber (doctor).
  • Describe why the request is urgent.
  • Have the prescribers' signature.

Requests will only be treated as urgent for documented clinical reasons. Otherwise the request will be processed normally.

How is the formulary developed?

How is the Formulary Developed?

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.

Quarterly updates are listed on the formulary page for each specific formulary on the website.

How are drugs classified?

How are drugs classified as generic or brand?

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.