Medicare Advantage Exceptions to the Formulary

Medicare Advantage Formulary & Criteria

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.

Exceptions include:

  • 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) 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. 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.

If you are a current member and a drug you are taking 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.

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