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 (Kanjinti, 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 Fulphila, Nyvepria, Udencya covered without PA |
Frequently requested medical benefit medications
| HCPCS Code | Brand Name | Generic Name | Reason | Clinical Resource |
|---|---|---|---|---|
| J0177, J0178 | Eylea, Eylea HD | aflibercept, aflibercept high dose | Covered without PA | Clinical Resource |
| J0179 | Beovu | Brolucizumab-dbll | Covered without PA | Clinical Resource |
| J2777 | Lucentis | Ranibizumab | Covered without PA | Clinical Resource |
| J2778 | Vabysmo | Faricimab-svoa | Covered without PA | 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 |
| J7999, C9257 | Avastin | Bevacizumab | Covered without PA Avastin covered for Ophthalmology procedures without PA | Clinical Resource |
| Q5124 | Byooviz | Ranibizumab-nuna | Covered without PA | Clinical Resource |
| Q5128 | Cimerli | Ranibizumab-eqrn | Covered without PA | Clinical Resource |