Does Quartz Health Solutions Cover Viagra?

Quartz Health Solutions Formulary and Sildenafil Coverage

Quartz Health Solutions, a regional insurer operating primarily in Wisconsin and parts of Illinois, Iowa, and Minnesota, maintains a multi-tier formulary that determines prescription drug coverage. Generic sildenafil appears on most Quartz formularies, though the specific tier, copay, and quantity restrictions vary by plan type.

How Quartz Formulary Tiers Work

Quartz uses a tiered formulary system common among commercial health plans. Tier 1 includes the lowest-cost generics. Tier 2 covers preferred generics and some preferred brand drugs. Tier 3 captures non-preferred generics and brands, and Tier 4 includes specialty medications. Sildenafil for erectile dysfunction (ED) typically falls on Tier 2 or Tier 3, depending on the specific Quartz product a member holds [1].

Brand Viagra vs. Generic Sildenafil

Pfizer's brand-name Viagra lost U.S. Patent exclusivity in 2017, and multiple generic manufacturers entered the market. The FDA's Orange Book lists over a dozen approved generic sildenafil products rated as therapeutically equivalent (AB-rated) to brand Viagra [2]. Because generics cost a fraction of the former brand price, insurers including Quartz shifted coverage exclusively to generic formulations. Members who request brand-name Viagra, if still available through any supplier, would face full out-of-pocket cost.

Confirming Your Specific Plan

The most reliable way to verify coverage is to log in to the Quartz member portal or call the number on your insurance card. Quartz updates its formulary at least annually, and mid-year changes can occur. Asking your pharmacist to run a test claim is another fast method to confirm tier placement and copay amount before filling a prescription.

Prior Authorization and Quantity Limits

Many insurers apply utilization management tools to ED medications. Quartz is no exception. These tools control costs and encourage clinically appropriate prescribing.

Prior Authorization Requirements

Some Quartz plans require prior authorization (PA) for sildenafil when prescribed for erectile dysfunction. PA typically involves your prescribing clinician submitting documentation that confirms a diagnosis of ED and that the medication is medically appropriate. The American Urological Association (AUA) guidelines recommend PDE5 inhibitors as first-line pharmacotherapy for ED, which generally satisfies PA criteria [3]. Approval turnaround is usually 24 to 72 hours for standard requests and within 24 hours for urgent requests.

Quantity Limits

Quartz commonly limits sildenafil fills to 6 to 12 tablets per 30-day supply. This restriction mirrors industry norms. A 2019 analysis published in the Journal of Sexual Medicine found that 87% of U.S. Commercial plans imposed quantity limits on PDE5 inhibitors, with a median cap of 8 tablets per month [4]. If your clinician believes a higher quantity is medically necessary, they can submit a quantity limit exception request to Quartz.

Step Therapy Protocols

Quartz may require step therapy for newer or more expensive ED treatments. This means a member must try and document an inadequate response to sildenafil before the plan will cover tadalafil (Cialis), vardenafil, or avanafil. Step therapy follows evidence-based treatment sequencing recommended by the AUA [3].

Cost Breakdown: What You Will Pay

Out-of-pocket costs for sildenafil under Quartz depend on your plan design, pharmacy choice, and whether you have met your annual deductible.

Copay Estimates by Plan Type

On a Quartz Tier 2 plan, generic sildenafil copays typically range from $10 to $25. On Tier 3 plans, copays may reach $30 to $50. High-deductible health plans (HDHPs) paired with a Health Savings Account (HSA) require members to pay full cost until the deductible is met, which could mean $20 to $80 per fill at prevailing generic rates. According to GoodRx market data, retail cash prices for generic sildenafil 100 mg (6 tablets) generally fall between $15 and $70 depending on pharmacy [2].

Preferred Pharmacy Networks

Quartz offers preferred pharmacy networks, and filling prescriptions at a preferred pharmacy can reduce copays by $5 to $15 compared to out-of-network pharmacies. Mail-order pharmacy options through Quartz may provide 90-day supplies at a reduced per-tablet cost.

Manufacturer and Pharmacy Discount Programs

Even with insurance, some members find that discount programs offer a lower price than their copay. Comparing your Quartz copay against cash-pay discount prices at your pharmacy is worth doing, particularly if you are on a high-deductible plan and have not yet met your deductible.

Sildenafil for Pulmonary Arterial Hypertension vs. Erectile Dysfunction

Sildenafil carries two distinct FDA-approved indications, and insurance coverage rules differ sharply between them. Revatio (sildenafil 20 mg) is approved for pulmonary arterial hypertension (PAH), while sildenafil 25 mg, 50 mg, and 100 mg tablets are approved for ED [5].

Why the Indication Matters for Coverage

Quartz, like most insurers, covers sildenafil for PAH under its medical or specialty pharmacy benefit with fewer restrictions, because PAH is a life-threatening condition. The 2022 ESC/ERS guidelines for pulmonary hypertension recommend PDE5 inhibitors as a first-line treatment for WHO Group 1 PAH [6]. Coverage for the ED indication, by contrast, falls under the prescription drug benefit and is subject to the quantity limits and PA requirements described above.

Coding and Billing Considerations

Your prescriber's diagnosis code determines which coverage pathway applies. ICD-10 code N52.9 (male erectile dysfunction, unspecified) triggers ED-specific formulary rules. ICD-10 code I27.0 (primary pulmonary hypertension) or I27.2 routes through the PAH benefit. Incorrect coding can result in claim denials that are entirely avoidable with accurate documentation.

Quartz Medicare Advantage and ED Medication Coverage

Medicare Part D has historically excluded ED medications from required coverage. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 allowed plans to exclude drugs used for ED from formularies [7]. Quartz Medicare Advantage plans follow this federal framework.

What This Means for Quartz Medicare Members

If you are enrolled in a Quartz Medicare Advantage plan, sildenafil for ED is likely not covered. You would pay full cash price. Some Medicare Advantage plans have begun offering supplemental drug benefits that include ED medications, but this varies by plan year and geographic service area. Contact Quartz directly or review your plan's Evidence of Coverage (EOC) document to confirm.

Alternatives for Medicare Members

Medicare members who cannot get coverage for sildenafil have several options. Cash-pay generic sildenafil is affordable at many pharmacies. Penile injection therapy with alprostadil may be covered under Medicare Part B when administered in a clinical setting. Vacuum erection devices are also covered as durable medical equipment under Part B with a physician's prescription [8].

How to Appeal a Coverage Denial

If Quartz denies coverage for sildenafil, you have the right to appeal. The appeals process follows both Quartz internal procedures and state insurance regulations.

Internal Appeal Steps

First, request a written explanation of the denial, including the specific formulary or medical policy cited. Your prescriber then submits a letter of medical necessity explaining why sildenafil is appropriate for your condition. Include relevant clinical documentation: diagnosis, prior treatments tried, comorbidities, and any contraindications to alternative therapies. The AUA notes that PDE5 inhibitors have Level A evidence supporting their use as first-line therapy for ED [3].

External Review

If the internal appeal is denied, Wisconsin residents can request an external independent review through the Wisconsin Office of the Commissioner of Insurance (OCI). This review is conducted by an independent physician who evaluates whether the denial was clinically appropriate. The external reviewer's decision is binding on the insurer.

Timeline Expectations

Quartz must respond to standard internal appeals within 30 days for non-urgent requests. Urgent (expedited) appeals require a response within 72 hours. External review decisions typically arrive within 45 days of filing.

Clinical Evidence Supporting PDE5 Inhibitor Use

Understanding the clinical evidence behind sildenafil can strengthen both prescribing decisions and insurance appeals.

Efficacy Data

Sildenafil was the first PDE5 inhibitor approved by the FDA, in 1998. A key meta-analysis published in BMJ pooling 27 randomized controlled trials (N = 6,659) found that sildenafil significantly improved erectile function across all ED severity levels compared with placebo, with 57% to 84% of attempts resulting in successful intercourse depending on dose [9]. A more recent Cochrane systematic review confirmed PDE5 inhibitors as effective and generally well-tolerated treatments for ED [10].

Safety Profile

Common side effects include headache (16%), flushing (10%), dyspepsia (7%), and nasal congestion (4%), based on FDA labeling data [5]. Serious adverse events are rare. Sildenafil is contraindicated with nitrate medications due to the risk of severe hypotension. The ACC/AHA guidelines recommend a 24-hour washout period between sildenafil use and nitrate administration [11].

Cardiovascular Safety

A concern sometimes raised by patients and insurers is cardiovascular risk. A 2021 meta-analysis in the Journal of the American Heart Association (18 studies, N = 10,000+) found no increased risk of major adverse cardiovascular events with PDE5 inhibitor use, and some studies suggested a possible cardioprotective effect [12]. The Princeton III Consensus guidelines state that men at low cardiovascular risk can safely use PDE5 inhibitors without cardiac workup [13].

Comparing Quartz Coverage to Other Wisconsin Insurers

Quartz is one of several insurers operating in Wisconsin. Coverage policies for ED medications differ across carriers.

Regional Coverage Field

Most Wisconsin commercial insurers, including Dean Health Plan (now part of Quartz), Group Health Cooperative of South Central Wisconsin, and Security Health Plan, cover generic sildenafil on their formularies with similar quantity limits. UnitedHealthcare and Anthem plans sold in Wisconsin also generally cover generic sildenafil at Tier 2. The key differentiator across plans is usually the copay amount and whether PA is required.

Marketplace Plan Considerations

If you are shopping for coverage on the Healthcare.gov marketplace during open enrollment, compare formularies before selecting a plan. Wisconsin marketplace plans must cover at least one drug per therapeutic class, but ED medications are not part of a required class. Plans that do include sildenafil may vary in tier placement, and checking the plan's formulary PDF before enrolling can prevent unexpected costs.

Talking to Your Doctor About Coverage and Alternatives

A direct conversation with your prescriber about insurance coverage can save time and money.

Prescriber-Driven Solutions

Your doctor can check Quartz's electronic prior authorization system (ePA) at the point of prescribing to determine real-time coverage status. If sildenafil is not covered or the copay is prohibitive, your prescriber may recommend tadalafil daily (2.5 mg or 5 mg), which some Quartz plans cover under a different formulary pathway for benign prostatic hyperplasia (BPH) with concurrent ED, using ICD-10 code N40.1 [14]. This approach is clinically appropriate when both conditions are present.

Non-Pharmacologic Options

The AUA guidelines also recognize lifestyle modifications, including regular aerobic exercise, weight loss, smoking cessation, and moderation of alcohol intake, as evidence-based interventions that improve erectile function [3]. A 2018 meta-analysis in the Journal of Sexual Medicine found that aerobic exercise alone improved IIEF scores by 3.85 points on average (N = 385 across 10 RCTs), a clinically meaningful improvement [15].