2025 Pharmacy Coverage
Commercial Large Group - Iowa, Minnesota, Wisconsin
Understanding what Quartz covers and what you'll pay for drugs
Intro text goes here – need to say something about this being for large groups in Iowa, Minnesota, Wisconsin that haven’t renewed yet in 2025.
2025 prescription drug coverage
If you have an employer-sponsored health plan….
For questions or to verify your plans coverage, please contact Member Services at (800) 496-7509.
<Link to 2T Formulary PDF>
<Link to 3T Formulary PDF>
<Link to 4T Formulary PDF>
Helpful resources for your pharmacy and prescription needs
Exceptions to the Formulary
The formulary is a list of medications that are covered by Quartz. If the member is taking a medication that is not on the formulary, you 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 you believe the member has a medical reason for an exception, you can request an exception by submitting a Coverage Determination Request.
Common Tier Exception Requests include:
- Tier 4 (Non-Preferred Drugs) your doctor can ask us to cover it at the lower copay cost applicable to formulary alternatives in a lower cost-sharing tier (if applicable).
- Tier 2 (Generic), your doctor can ask us to cover it at the lower copay cost applicable to formulary alternatives in Tier 1 (if applicable).
Tier Exceptions are not allowed for:
- Brand Drugs to be covered at Generic tiers (unless there is a brand drug covered at that tier).
- Brand or Generic Drugs when there are no formulary alternatives covered at a lower tier.
- Specialty drugs (Tier 5) are not eligible for a tier exception.
What to do if your drug is not on the formulary
- Change to another drug. Determine if another drug is on the formulary that might work just as well for the member.
- Submit a formulary exception request. Ask for an exception to see if Quartz will cover a non-formulary drug due to medical reasons. Such reasons include: – all of the similar drugs on the formulary would not be effective for the member or -they would cause side effects for the member.
If the current member uses a drug that will be removed from the Formulary or restricted in some way for next year, we will allow you to request an exception in advance for the next year. We will give you an answer to your request for an exception before the change takes effect.
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 patients using approved medications. The goal is to help the patients 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 patient 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. You 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 your medication is part of the program and/or requires a prior authorization, review the Quartz Formulary.
How to get your medicines from the Specialty Pharmaceutical Program
If the medication requires a Prior Authorization, have your doctor or nurse submit a Medication Prior Authorization Form for your medication to the Quartz Pharmacy Program.
Call to start the enrollment process at one of our Participating Specialty pharmacies:
- Aurora Specialty Pharmacy at (844) 820-5600
- Gundersen Health System Pharmacies at (877) 208-1096
- UW Health Pharmacy at (866) 894-3784
- UW Health Northern Illinois Pharmacy at (888) 861-0854
Answer the questions from pharmacy staff. They will also discuss delivery or pick-up. They will contact your doctor or nurse to get a copy of the prescription.
Program Disclaimers:
This program does not apply to drugs given by a doctor or nurse in a clinic, hospital, or other health care facility. This program DOES NOT apply to members covered under the State of Wisconsin Health Insurance Program, those who have Navitus for their drug benefit, or members with BadgerCare Plus. Any Wisconsin pharmacy that is in Quartz’s participating pharmacy network, and can meet the terms and conditions, can participate in the Quartz Specialty Pharmaceutical Program. Pharmacies may contact the Quartz Pharmacy Program at (888) 450-4884 for a copy of the terms and conditions, or to apply to participate.
Contact us
Quartz is here to help. That’s why we make it easy to reach us.
Call Quartz Customer Success (844) 644-3455 or message us on Quartz MyChart.