Provider Pharmacy Program
The Quartz Pharmacy Program is based on local medical practice patterns and managed following NCQA best practices, this program helps provide effective medication management for patients.
Patient Medication Costs
You can determine the copay level (tier) for your patient’s medications by reviewing Quartz’s Drug Formulary. The formulary lists medications by drug class according to the copay tier.
Quartz populates formulary information with the Surescripts hub for use in e-prescribing applications. Surescripts will display the copay tier of the medication.
Certain medications require prior authorization before coverage is provided.
Quartz’s Specialty Pharmaceuticals Program
Quartz’s Specialty Pharmaceutical Program provides high-quality clinical monitoring for patients using specialty medications while helping keep coverage of these products affordable.
The Quartz Drug Formulary includes the designation of “SP” if the medication is in the Specialty Pharmaceuticals program. Call UW Health Pharmacy at (866) 894-3784 or Gundersen Health System Pharmacies at (877) 208-1096 with questions or to help enroll a patient in the Specialty Pharmaceuticals program.
Please note: The Specialty Pharmaceuticals Program does not apply to medications administered in the physician’s office, a hospital or other health care facility.
Vendor Solution Drug Program
Pharmaceuticals provide much-needed innovative therapies for patients. However, they also have a significant impact on health care costs. When those drugs are administered in a health care setting, the price markup ranges from 2-10 times the facility’s cost. And costs continue to rise, often creating a significant financial burden for patients who need these drugs. Quartz has a similar burden for our share of the costs.
At Quartz, we believe in helping our members get the care they need at the right cost. That’s why we are implementing changes in our reimbursement practices for drugs given in the doctor’s office or other health care settings.
What does this mean for providers?
Quartz is offering providers three options, from preferred to least preferred:
- Accept ASP contract terms. In this scenario, your drug procurement and administration policies would not change; you would just be reimbursed at a new contracted rate.
- Decline ASP contract terms but allow Accredo specialty pharmacy to supply certain drugs to you for administration as usual (commonly referred to as “white bagging”). This would change your procurement processes for this group of drugs. You would not bill Quartz for these — we would reimburse the specialty pharmacy.
- Decline ASP contract terms, and decline receiving drug orders from Accredo. In this case, Quartz would redirect care for your patient so they will receive their prescription (furnished by Accredo) either in their home or at another location.
What drugs are affected?
The following drugs are included, initially, in the program:
- Abatacept IV (Orencia)
- Agalsidase beta (Fabrazyme)
- Alglucosidase alfa (Lumizyme)
- alpha-1 proteinase inhibitor (Aralast NP, Glassia, Zemaira)
- Belimumab (Benlysta)
- Benralizumab (Fasenra)
- Burosumab (Crysvita)
- Canakinumab (Ilaris)
- Denosumab (Prolia, Xgeva)
- Dupilumab (Dupixent)
- Eculizumab (Soliris)
- Epoprostenol (Veletri)
- Givosiran (Givlaari)
- Immune globulin (Asceniv, Bivigam, Cutaquig, Cuvitru, Gammagard Liquid, Gammagard S-D, Gammaked, Gammaplex, Gamunex-C, Hizentra, HyQvia, Octagam, Panzyga, Privigen, and Xembify)
- Infliximab (Remicade) – brand not covered; use biosimilar
- Infliximab biosimilar (Renflexis, Inflectra, Ixifi, Avsola)
- Mepolizumab (Nucala)
- Natalizumab (Tysabri)
- Ocrelizumab (Ocrevus)
- Omalizumab (Xolair)
- Palivizumab (Synagis)
- Pegloticase (Krystexxa)
- Ravulizumab (Ultomiris)
- Romiplostim (Nplate)
- Romosozumab-aqqg (Evenity)
- Sebelipase alfa (Kanuma)
- Teprotumumab (Tepezza)
- Tildrakizumab (Illumya)
- Treprostinil (Remodulin)
- Ustekinumab (Stelara)
- Vedolizumab (Entyvio)
This list will expand as other drugs are identified in the future that generate additional savings through this program.
How will providers know if a drug for a Quartz member is required to be obtained from Accredo or not?
Before program implementation, we will send your providers or PA coordination department a list of current Quartz members receiving designated medications at your facility who will need to obtain those medications from the specialty pharmacy.
Future prior authorization approvals for designated medications will include details for procuring the drugs, including through Accredo, if that is the case. Included drugs are noted in the answer to the above question, “What drugs are affected?”.
What role will members play in all of this?
If the provider accepts ASP contract terms or agrees to receive the specialty drug from Accredo, Quartz members won’t experience anything different (except potentially a lower cost-share). If the provider does not accept ASP or the vendor solution, we may redirect care to have the member’s medicine administered in the home or elsewhere.
What resources are available to answer questions about which providers are required to obtain designated medications from Accredo?
Providers should direct questions to their Quartz contract manager.
What resources are available to providers to track shipments of designated medications?
MyAccredoPatients.com is an all-in-one portal that lets providers see referrals, check prior authorizations, track shipments, and more. It includes live chat with an Accredo agent.
Can exceptions be requested to the policy?
Yes, Quartz will allow a one-time exception in cases where the person has arrived at their appointment and drug from the Vendor Solution program is not available to be given. Quartz may consider requests for exceptions to this policy for other reasons based on medical necessity. Please follow established prior authorization and exception request processes as outlined in our Provider Manual.