Does Quartz Health Solutions Cover Adderall?

What Is Quartz Health Solutions and How Does Its Pharmacy Benefit Work?

Quartz Health Solutions is a Wisconsin-based, not-for-profit health insurer offering commercial individual and family plans, employer group plans, Medicare Advantage, and marketplace plans across Wisconsin and parts of Minnesota and Illinois. Its pharmacy benefit is managed through a tiered formulary, meaning drugs are grouped into cost levels (Tier 1 through Tier 4 or 5 on most plans), with member cost-sharing increasing at each tier.

Adderall (amphetamine/dextroamphetamine mixed salts) is a Schedule II controlled substance approved by the FDA for attention-deficit/hyperactivity disorder (ADHD) in children aged 6 and older and in adults [1]. Because it is a controlled substance, insurers including Quartz apply additional utilization-management tools beyond simple tiering. Those tools typically include prior authorization, quantity limits (often a 30-day supply maximum per fill), and, for brand-name products, step-therapy requirements that mandate a trial of the lower-cost generic first.

The practical upshot: generic amphetamine mixed salts IR (immediate-release) and generic amphetamine mixed salts XR (extended-release) are almost always on the Quartz formulary and covered once standard medical-necessity criteria are met. Brand-name Adderall and brand-name Adderall XR face stricter hurdles. Members should pull the current-year Summary of Benefits and Coverage (SBC) and the plan's drug formulary directly from the Quartz member portal at quartz.com, because formulary tiers can shift January 1 of each plan year.

Is Generic Adderall the Same Drug, and Does Quartz Treat It Differently?

Generic amphetamine mixed salts are therapeutically equivalent to brand-name Adderall. The FDA requires generics to demonstrate bioequivalence, meaning the active ingredient reaches the bloodstream at a rate and extent within 80-125% of the brand product [2]. Clinically, the two are considered interchangeable for most patients.

Quartz, like most insurers, places the generic on a lower cost-sharing tier than the brand. On a typical Quartz commercial plan, generic amphetamine salts IR 20 mg sits at Tier 2 (preferred generic), with a copay in the $10-$40 range per 30-day supply depending on your specific plan design. Brand Adderall, if it appears on the formulary at all, typically sits at Tier 3 or Tier 4, with a copay or coinsurance that can reach $50-$150 or more per fill before deductible.

One practical note: the ongoing national shortage of amphetamine mixed salts, which the FDA has tracked since late 2022, has caused sporadic unavailability at pharmacies across Wisconsin [3]. A covered drug that a pharmacy cannot currently stock is not the same as a coverage denial. If your pharmacy is out of stock, call Quartz member services (number on the back of your card) to ask about an authorized out-of-network pharmacy fill or a 90-day mail-order supply from Quartz's pharmacy benefit manager.

Prior Authorization for Adderall Through Quartz: What Triggers It and What You Need

Prior authorization (PA) is a formal insurer review that your prescriber must complete before Quartz will approve payment for the medication. For brand-name Adderall or Adderall XR, PA is standard on virtually all Quartz plans. Some Quartz plans also require PA for generic amphetamine salts above certain daily doses (commonly above 40 mg/day in adults or above 30 mg/day in pediatric patients).

The PA process typically requires:

1. A confirmed DSM-5 diagnosis of ADHD. The DSM-5 specifies that at least five inattentive or five hyperactive-impulsive symptoms must be present for six or more months in adults, with onset before age 12 and impairment in two or more settings [4]. Your prescriber's chart notes should document these criteria explicitly.

2. Documentation of functional impairment. Quartz's medical-necessity language generally requires evidence that ADHD symptoms are causing clinically significant impairment in occupational, academic, or social functioning. Rating scales such as the Adult ADHD Self-Report Scale (ASRS) or the Conners' Rating Scale are commonly accepted.

3. Prior-treatment history (for brand-name requests). Step-therapy requirements mean your prescriber must show that the patient tried a generic amphetamine product and either did not respond adequately or had a documented intolerance. A brief trial is typically defined as at least 30 days at an adequate dose, though some Quartz PA forms accept documented intolerance after a shorter period.

4. Prescriber attestation. The prescriber signs and submits the PA request, usually through CoverMyMeds or directly via fax to Quartz's pharmacy prior-authorization department. Quartz is required under Wisconsin Ins. 3.37 and federal Consolidated Appropriations Act (CAA) 2021 transparency rules to provide a PA determination within 3 business days for standard requests and 1 business day for urgent requests.

The framework below summarizes a practical three-step PA submission approach that the HealthRX clinical team uses when advocating for patients whose Quartz PA was initially flagged for incompleteness:

Step 1 (Day 0): Confirm the correct PA form. Quartz uses specific PA forms by drug class. Request the "CNS Stimulant Prior Authorization Criteria" form through the Quartz provider portal or by calling provider services at 1-800-362-3310.

Step 2 (Day 0-1): Gather clinical documentation. Collect the ADHD rating scale scores, the DSM-5 symptom checklist from the clinical note, any prior-medication trial records, and a brief functional-impairment summary. If the patient is an adult diagnosed after age 18, include records of retrospective symptom onset before age 12 if available.

Step 3 (Day 1-2): Submit and track. Use CoverMyMeds for electronic submission with an automatic tracking number. Follow up at 72 hours. If no determination has been received, escalate to Quartz provider relations; under Wisconsin Administrative Code, a missed determination deadline can be treated as an adverse determination and appealed immediately.

Step Therapy: Which Medications Must Be Tried Before Brand Adderall?

Step-therapy, sometimes called "fail-first," requires a patient to try one or more lower-cost medications before Quartz will approve coverage for a higher-cost agent. For brand-name Adderall XR specifically, Quartz typically requires prior adequate trials of:

• Generic amphetamine mixed salts XR (the generic equivalent of Adderall XR)
• Generic methylphenidate XR (e.g., generic Concerta or generic Ritalin LA)

Each trial is generally defined as 30 days at an adequate dose with documented clinical response. Step-therapy requirements must have an exception process under federal law. The CAA 2021, Section 116, requires commercial insurers to grant a step-therapy exception when the required drug is contraindicated, likely to cause an adverse reaction, or when the patient previously tried and failed the step-therapy drug. Your prescriber can submit a step-therapy exception request alongside the PA using the same CoverMyMeds workflow.

The American Academy of Pediatrics 2019 Clinical Practice Guideline for ADHD states: "For children 6 years and older, FDA-approved medications for ADHD should be prescribed" and does not endorse any mandatory step-therapy sequence as clinically superior [5]. This guideline language can support a step-therapy exception request when a prescriber believes a specific formulation is medically necessary from the outset.

Adderall for Adults vs. Children: Does Quartz Apply Different Rules?

FDA approval covers amphetamine mixed salts for ADHD in patients aged 6 and older, with no upper age limit specified in the labeling [1]. Quartz's coverage policies generally mirror the FDA label. Both pediatric and adult patients require a confirmed ADHD diagnosis and, for brand products, a PA.

One area where adult coverage sometimes differs: some Quartz employer group plans include behavioral-health carve-outs managed by a separate PBM or mental-health administrator. If your employer's plan has a carve-out, the PA for a stimulant medication may need to be submitted to that separate entity rather than directly to Quartz. Check your SBC under "Mental Health and Substance Use Disorder Services" to see if a carve-out applies.

Adult ADHD prevalence data from the CDC's 2023 National Health Interview Survey estimates that approximately 4.4% of U.S. adults carry an ADHD diagnosis, up from 3.1% in 2020, reflecting both increased diagnosis rates and greater treatment-seeking behavior [6]. Insurers have responded to this volume increase with tighter utilization management, which is part of why PA rates for stimulants have increased across commercial plans since 2021.

What If Quartz Denies Coverage? The Appeals Process

A denial letter from Quartz must include the specific clinical reason for denial, the clinical criteria used, and instructions for appeal. Under Wisconsin insurance law and the ACA's internal-appeals requirement, you have the right to an internal appeal within 180 days of receiving a denial notice.

Internal Appeal. Your prescriber submits a written appeal with additional clinical documentation. Standard internal appeals receive a decision within 30 calendar days; urgent (expedited) appeals receive a decision within 72 hours. Quartz's appeals address is on the denial letter, and appeals may also be submitted through the provider portal.

External Review. If the internal appeal is denied, Wisconsin residents have the right to external review by an independent review organization (IRO) approved by the Wisconsin Office of the Commissioner of Insurance (OCI). The IRO's decision is binding on Quartz. The external review request must be submitted within 4 months of the final internal denial.

Wisconsin OCI Complaint. If Quartz does not follow required timelines or fails to provide adequate denial reasoning, a complaint can be filed with the Wisconsin OCI at oci.wi.gov. The OCI has authority to investigate and mandate corrective action.

A 2022 analysis published in JAMA Network Open found that among commercial insurance appeals for prior-authorization denials, approximately 35% of appeals resulted in overturned decisions when adequate clinical documentation accompanied the appeal [7]. Submitting complete documentation at the first appeal matters.

Non-Stimulant Alternatives That Quartz Typically Covers

If PA for amphetamine mixed salts is denied or if a patient cannot tolerate stimulant medications, Quartz formularies typically include several non-stimulant ADHD options, often at Tier 1 or Tier 2.

Atomoxetine (generic Strattera). A selective norepinephrine reuptake inhibitor approved for ADHD in adults and children aged 6 and older [8]. In a 10-week randomized controlled trial (N=536), atomoxetine produced a statistically significant reduction in ADHD-RS-IV scores vs. placebo (P<0.001) [9]. Generic atomoxetine is widely available and generally at Tier 2 on Quartz plans.

Guanfacine ER (generic Intuniv). An alpha-2A adrenergic agonist FDA-approved for ADHD in patients aged 6-17. In a phase III trial (N=324), guanfacine ER significantly reduced ADHD-RS-IV scores vs. placebo at 8 weeks (P<0.001) [10]. Covered as Tier 1 or 2 generic on most Quartz plans.

Clonidine ER (generic Kapvay). Another alpha-2 agonist, FDA-approved for ADHD as adjunctive therapy. Typically Tier 1 generic on Quartz formularies.

Viloxazine ER (Qelbree). A newer non-stimulant approved in 2021 for pediatric ADHD (ages 6-17), with a 2023 adult approval. It tends to sit at Tier 3 with PA requirements on most Quartz plans, though step-therapy criteria may be less stringent than for brand stimulants.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for ADHD notes that stimulants remain first-line treatment, with "effect sizes of 0.8 to 1.0 in children," compared to effect sizes of approximately 0.5-0.7 for non-stimulant agents [11]. This evidence gap is relevant context when a prescriber is writing a PA letter arguing for stimulant therapy over a non-stimulant alternative.

How to Verify Your Specific Quartz Plan's Adderall Coverage Right Now

Coverage tiers, PA criteria, and cost-sharing amounts change annually on January 1. The only authoritative source for your plan's current coverage is the plan's own documentation. Here are the fastest verification methods:

Method 1: Quartz Member Portal Drug Search. Log in at quartz.com, manage to "My Coverage," then "Drug Formulary." Search "amphetamine" or "Adderall." The formulary tool shows the current tier, any PA flag, quantity limits, and the specific PA criteria document.

Method 2: Quartz Member Services Phone Line. Call the number on the back of your insurance card. Ask: "Is amphetamine mixed salts [dose and formulation] covered on my plan? Is prior authorization required? What is the PA criteria document number?" Document the representative's name, date, and reference number.

Method 3: Prescriber's Office. Most prescribers use an electronic benefits verification (eBV) tool that pulls real-time formulary data. Ask the prescriber's office to run a benefits check before submitting the prescription.

Method 4: Pharmacy Benefits Real-Time Adjudication. Ask the pharmacy to attempt to adjudicate (run) the prescription. If it rejects, the reject code will specify whether the denial is for PA, step therapy, quantity limits, or a non-formulary status. That code tells your prescriber exactly what documentation to submit.

The FDA's current list of drug shortage products, including amphetamine mixed salts, is updated weekly and can be checked at accessdata.fda.gov to distinguish a coverage issue from a supply-chain issue [3].

Cost Without Coverage and Savings Programs

If coverage is denied pending appeal, or if a patient chooses to pay out of pocket while the PA is processed, the cost of generic amphetamine mixed salts varies significantly by pharmacy and formulation.

Generic amphetamine salts IR 20 mg (30 tablets): approximately $30-$60 cash price at major chains; $18-$35 with GoodRx or a similar discount card as of early 2025.

Generic amphetamine salts XR 20 mg (30 capsules): approximately $60-$110 cash price; $35-$65 with discount cards.

Brand Adderall XR 20 mg (30 capsules): $250-$350 cash price without any savings program.

Shire (now Takeda) no longer markets a manufacturer savings card for brand Adderall XR as of 2023, because the product lost exclusivity. Generic amphetamine XR dominates the market. Patients who are uninsured or underinsured may qualify for patient assistance through NeedyMeds (needymeds.org) or RxAssist, though those programs are separate from any Quartz coverage determination.