Medical Benefit Drug Restriction Information

About medical benefit drug restrictions

Restricted medical benefit drugs are medications administered through the medical benefit and require an approved authorization prior to being given in a clinic, hospital, or infusion center location. 

Some state and federal laws require Quartz to cover specific drugs for some benefits that are excluded for others. Certain drugs with medical benefit restrictions may not be covered by the specific medical benefit plan. 

For a detailed explanation of the medical benefit, refer to the Quartz Certificate of Coverage or your Summary Plan Description. You can also contact Quartz Customer Success at (800) 362-3310 to verify your coverage.

Medical drug benefit classifications

To understand your medical benefit drug restrictions, it’s important to understand three key medical drug classifications you may encounter.

Prior authorization/step therapy: These products have specific criteria for use and an approved authorization/step exception is required for coverage. A medication coverage request form will need to be completed and submitted for review.

Exclusions:  These products are not covered by the Quartz medical benefit plan. Examples include hair loss drugs, sexual enhancement drugs, infertility drugs, most over-the-counter drugs, cosmetic treatments, and nutritional supplements or medical foods. Please refer to the Certificate of Coverage or Summary Plan Description to view specific exclusions.

Medical necessity: These products are not initially covered under the Quartz medical benefit, but if your health care provider deems the product medically necessary for your care, an exception request can be submitted for review. If approved, the product classification can change to a “medical necessity,” making possible coverage options available. Common medical necessity examples include:

• • Biosimilar Substitution Policy:  This policy requires the use of biosimilars when available in most cases. Reference [brand name] biologics with available biosimilars are not covered.  

• • Injectable Self-Administered Drugs (SAD): Medications that are typically self-administered are not covered by the medical benefit. Medications listed as “USE RX BENEFIT” are blocked from coverage on the Medical Benefit. Refer to the formulary to determine coverage status.

• • Not covered, medical benefit: These products are considered Not Covered under the Quartz medical benefit.

• • Vaccines: Gardasil (HPV) and Shingrix (Zoster) are programmed for age recommendations based on the Disease Control and Prevention Advisory Committee of Immunization Practices (ACIP). Use outside of programmed age limits requires medical necessity.

Other important information

Some medications require the use of Vendor Solutions. For the list of medications and more details about Vendor Solutions, go here. https://quartzbenefits.com/providers/provider-pharmacy-program/

CART-Therapy medications are reviewed by medical management and fall under medical policies. Refer here for details. https://quartzbenefits.com/providers/provider-medical-policies/

Medical Benefit Biosimilars Information

HCPCS Code	Brand Name	Generic Name	Reason	Clinical Resource
J9035	Avastin	Bevacizumab	Biosimilars (Alymys, Mvasi, Zirabev) covered without PA; Avastin ONLY covered for Ophthalmology procedures	Bevacizumab Clinical Resource
J1745 Q5104 (Renflexis) Q5109 (Ixifi)	Remicade	infliximab	Biosimilar Inflectra, Avsola are covered without PA	Infliximab Clinical Resource
J1442	Neupogen	Filgrastim	Biosimilars (Nivestym, Zarxio, Releuko) covered in clinics without restrictions. Granix (tbo-filgrastim) also covered without restrictions	Filgrastim Clinical Resource
J9312	Rituxan	Rituximab	Biosimilars (Truxima, Riabni, Ruxience) covered without PA	Rituximab Clinical Resource
J9355	Herceptin	Trastuzumab	Biosimilars (Kadcycla, Enhertu, Kanjinti, Ogiviri, Ontruzant, Herzuma, Trazimera) covered without PA	Trastuzumab Clinical Resource
J0885 J0886 Q4081	Procrit Epogen	Epoetin alfa	Biosimilar (Retacrit) covered in clinics without restrictions
J2506 96377	Neulasta ONPRO	Pegfilgrastim	Biosimilars (Stimufend, Fylnetra, Ziextenzo) covered with PA. Biosimilars Fulphila, Nyvepria, Udenyva covered without PA.

Common products requested as a medical necessity- Others

HCPCS Code	Brand Name	Generic Name	Comment
J0172	Aduhelm	Aducanumab-avwa
J1426	Amondys	Casimersen	*For Quartz BadgerCare Plus and/or Medicaid SSI
J1428	Exondys 51	Eteplirsen	*For Quartz BadgerCare Plus and/or Medicaid SSI
J1429	Vyvondys 53	Golodirsen	*For Quartz BadgerCare Plus and/or Medicaid SSI
J1427	Viltepso	Viltolarsen	*For Quartz BadgerCare Plus and/or Medicaid SSI

Frequently requested medical benefit medications

HCPCS Code	Brand Name	Generic Name	Reason	Clinical Resource
J7318	Durolane	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7320	Genvisc	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7321	Hyalgan, Supartz, Visco-3	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7322	Hymovis	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7324	Ortho-Visc	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7326	Gel-One	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7327	Monovisc	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource
J7328	Gelsyn-3	Hyaluronic acid derivatives, intraarticular injection	Synvisc, Synvisc-1 and Euflexxa covered without PA	Hyaluronic Acid Clinical Resource