Prior Authorization Criteria and Part D Formulary
Formulary and Prior Authorization Information
See the copay amounts for the different tiers.
For a list of the most common drugs that are either not covered or are in a non-preferred tier and their alternative covered or preferred drug, see our Alternative Drug List.
NOTE: FreeStyle Lite, FreeStyle Freedom Lite, FreeStyle Precision Neo, FreeStyle InsuLinx, and Precision Xtra These are the preferred blood glucose monitoring systems and test strips. Other test strips and meters are not covered as of 1/1/2021 (unless an exception request is approved). Test strips are limited to 200 strips per 30 days (unless exception request is approved).
Continuous Glucose Monitors (CGMs) covered at the pharmacy: Therapeutic CGMs (Freestyle Libre, FreeStyle Libre 2, and Dexcom G6) are covered at participating pharmacies with approved prior authorization. Prior authorization criteria are listed here.
Within the Formulary, you will see which drugs may have special requirements, including:
- Prior Authorization – You or your physician are required to get approval before you can fill a prescription for the drug.
- Step Therapy – You are required to try certain drugs to treat your health condition before Quartz Medicare Advantage will cover another drug for that condition.
- Quantity Limits – There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame.
These drugs are selected by Quartz Medicare Advantage in consultation with the Pharmacy and Therapeutics (P&T) Committee, a team of health care providers. This list represents the prescription therapies believed to be a necessary part of a quality treatment program. Quartz Medicare Advantage will generally cover the drugs listed in our Formulary as long as the drug is medically necessary, the prescription is filled at a Quartz Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC).
Brand and Generic Drugs
Quartz Medicare Advantage covers both brand-name drugs and generic drugs within the Formulary. Generic drugs have the same active ingredient formula as a brand-name drugs. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
Updating the Formulary
Formulary development and maintenance is an ongoing process. The P&T Committee regularly reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. The Formulary is updated periodically and changes are able to be seen by clicking on the Part D Drug Formulary link above.
Exceptions to the Formulary
The formulary is a list of medications that are covered by Quartz Medicare Advantage (HMO). If you are taking a medication that is not on the formulary, your doctor can ask for an exception to the formulary.
- 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 your doctor believes you have medical reasons for an exception, he or she can help you request an exception. They may submit a Coverage Determination Request.
Common Tier Exception Requests include:
- Tier 4 (Non-Preferred Drugs). If your medication is a brand name drug, your doctor can ask us to cover it at the lower copay cost of other drugs in Tier 3 (Preferred Brand).
- Tier 4 (Non-Preferred Drugs) If your medication is a generic drug, your doctor can ask us to cover it at the copay cost of lower-tiered alternative formulary drugs.
- Tier 2 (Generic), your doctor can ask us to cover it at the lower copay cost of other alternatives in Tier 1 (if applicable).
Tier Exceptions are not allowed for:
- Brand Drugs to be covered at Generic tiers
- Specialty drugs (Tier 5) are not eligible for tier exception.
What to do if your drug is not on the formulary:
- Change to another drug. Ask your doctor to see if another drug on the Quartz Medicare Advantage Formulary might work just as well for you.
- Submit a formulary exception request. Your doctor can ask for an exception so we 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 you or -they would cause side effects for you
- If Quartz Medicare Advantage approves your exception, it will be covered at a Tier 4 (Non-preferred drug) copay.