Exceptions to the formulary – Medicare Advantage Members
Exceptions to the Formulary
The formulary is a list of medications that are covered by Quartz Medicare Advantage (HMO). If the member is taking a medication that is not on the formulary, you 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 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 ion the Quartz Medicare Advantage Formulary 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 Quartz Medicare Advantage approves the exception, it will be covered at a Tier 4 (Non-preferred drug) copay.
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.