2027 Quartz formulary and pharmacy benefits
Individual & Family plans
Understand your plan’s prescription drug coverage
The formulary is the list of medications covered by Quartz through the prescription drug benefit. Below, you’ll find formularies for Individual & Family plans through the Health Insurance Marketplace (On Exchange) as well as plans purchased directly from Quartz (Off Exchange).
For questions or to verify a plan’s coverage, contact Member Services at (800) 496-7509.
Are you a current member?
To make sure you’re viewing details for your specific plan, visit the pharmacy benefits page in Quartz MyChart or use our formulary look-up tool.
View the standard formulary
How to determine what a medication may cost
Current members
- Log in to QuartzMyChart.com and click Pharmacy benefits, then Get pricing for a medication
- Cost information can also be accessed using the QuartzRx app. You will need to create an account if this is your first time using this service.
Not a current member?
- Look up a drug name in the formulary to find its tier and learn how it’s covered under the prescription drug benefit.
Drug tiers
Drug tiers determine coverage and cost. The higher the tier, the higher the cost.
- All pharmacy plans include $0 coverage for preventive drugs recommended by the U.S. Preventive Services Task Force (USPSTF).
- Standard Plans feature a 4-tier pharmacy benefit that is uniform across all payers, with cost-sharing determined by the Centers for Medicare and Medicaid Services (CMS).
View the non-standard formulary
How to determine what a medication may cost
Current members
- Log in to QuartzMyChart.com and click Pharmacy benefits, then Get pricing for a medication
- Cost information can also be accessed using the QuartzRx app. You will need to create an account if this is your first time using this service.
Not a current member?
- Look up a drug name in the formulary to find its tier and learn how it’s covered under the prescription drug benefit.
Drug tiers
Drug tiers determine coverage and cost. The higher the tier, the higher the cost.
All pharmacy plans include $0 coverage for preventive drugs recommended by the U.S. Preventive Services Task Force (USPSTF).
High Deductible Health Plans (HDHPs)
Members with a HDHP pay the cost of most covered prescription drugs until the deductible is met. These plans may also include:
- Coinsurance after the deductible is met
- Certain high-value and preventive drugs and supplies at $0 cost to members before the deductible is met (if listed on the formulary as “$0 HDHP” or placed on the $0 Tier)
Only the following plans include coverage at $0 for all $0 HDHP drugs on the formulary:
- Silver $6,500 HSA
- Bronze $8,500 HSA
- Catastrophic $12,000 Ded
To confirm your plan name, view your SBC in your Quartz MyChart account.
Helpful resources for your pharmacy and prescription needs
Check coverage and costs
Understand coverage requirements
Getting your medications
Formulary exception requests
The formulary is the list of medications covered by Quartz. If a member needs a medication that isn’t on the formulary, first consider whether another covered drug might work just as well — your provider can help review options. If no suitable alternative is available, an exception request may be an option.
When an exception may be needed
An exception can be requested when:
- Non-formulary drug: The medication isn’t covered by the plan, and no suitable alternative is available.
- All similar formulary drugs would not be effective
- Formulary drugs would cause harmful side effects
- Coverage restrictions: The drug is covered but has limits, such as:
- Step therapy – You may need to try a different drug first to see if it works before the requested drug can be covered.
- Quantity limit – There may be a maximum number of tablets or doses covered per day.
Requesting an Exception
If there is a medical reason why a member needs a drug outside the formulary or its restrictions, a provider can submit a Prior Authorization Request form to ask for an exception.
Specialty pharmaceuticals program
What is a specialty pharmaceutical?
Specialty pharmaceuticals are a group of high-cost medicines that are used to treat chronic health problems. These therapies tend to be more complicated and more costly than others. They may require special storage, regular lab testing, and screening tests and may be given by injection or orally. To get the most benefit, regular adherence to the regimen is needed.
What is the Quartz Specialty Pharmaceutical Program?
The Specialty Pharmaceutical Program provides high-quality clinical monitoring to members using approved medications. The goal is to help the members stay healthy and keep coverage of these medicines affordable. The majority of drugs included in Quartz’s Specialty Pharmacy network have pharmacist-run management programs to maximize member knowledge and outcomes from taking these medications. This may include additional follow-up from the pharmacist or partial dispensing protocols.
Specialty medications may require a prior authorization and must be provided by a pharmacy in the Specialty Pharmaceutical Program. Members will not be charged for shipping by standard mail. The medicine may also be picked up at the pharmacy. Medications included in this program are noted with an “SP.” To see if the medication is part of the program and/or requires a prior authorization, review the Quartz Formulary.
How to get medicines from the Specialty Pharmaceutical Program
If the medication requires a prior authorization, a doctor or nurse can submit a Medication Prior Authorization Form for the medication to the Quartz Pharmacy Program.
Members should call one of our participating specialty pharmacies to start the enrollment process:
- Advocate Health Specialty Pharmacy at (844) 820-5600
- Emplify Health by Gundersen Pharmacies at (877) 208-1096
- UW Health Pharmacy at (866) 894-3784
Members will need to answer a few questions from the pharmacy staff, and they’ll help arrange delivery or pick-up. They’ll also reach out to the doctor or nurse to get a copy of the prescription.
Program disclaimers:
This program does not apply to drugs given by a health care worker in a clinic, hospital, or other health care facility. This program does not apply to members covered under the State of Wisconsin Group Health Insurance Program, those whose prescription drug benefit is administered by Navitus, members with Quartz Medicaid coverage, or members with a Quartz plan sold in the state of Illinois.
Any pharmacy that is included in Quartz’s participating pharmacy network, and can meet the terms and conditions, may participate in the Quartz Specialty Pharmaceutical Program. Pharmacies may contact Quartz Customer Success at (800) 362-3310 for a copy of the terms and conditions or to apply to participate.
Vaccine coverage
Coverage of select immunizations is available under the pharmacy benefit. Simply present your Quartz ID card to a network pharmacy. Contact your local pharmacy for information about vaccine and appointment availability. Limitations and restrictions may apply.
Examples for vaccines that can be obtained under the pharmacy benefit include:
- COVID-19
- Influenza (flu)
- Pneumococcal (pneumonia)
- Shingles (herpes zoster)
- Tetanus/Whooping Cough (Tetanus, diphtheria, pertussis; Tdap)
- Hepatitis B
- HPV (human papilloma virus)
Transparency in coverage resource: PY2027 Formulary machine readable file
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