Does Quartz Health Solutions Cover Dupixent?

What Dupixent Is and Why Insurers Scrutinize It

Dupixent (dupilumab) is a fully human monoclonal antibody that blocks both IL-4 receptor alpha and IL-13 signaling. The FDA first approved it in March 2017 for adults with moderate-to-severe atopic dermatitis inadequately controlled by topical therapies [1]. Since then, the agency has added six more indications, most recently moderate-to-severe COPD with an eosinophilic phenotype in June 2024 [2].

Why the specialty tier matters

Specialty-tier drugs carry the highest member cost-sharing, often 25 to 35% coinsurance rather than a flat copay. At Dupixent's wholesale acquisition cost of roughly $39,000 per year, a 30% coinsurance obligation before the out-of-pocket maximum is met can exceed $11,000 annually. That math explains why insurers, including Quartz, attach prior authorization (PA) requirements to every claim.

The clinical case for dupilumab

LIBERTY AD SOLO 1 and SOLO 2 (combined N=1,379) showed that dupilumab 300 mg every two weeks produced an IGA 0/1 response in 37 to 38% of adults with moderate-to-severe atopic dermatitis at week 16, versus 8 to 10% for placebo (P<0.001) [3]. Those numbers justify the drug's cost for appropriate patients but also explain why payers want confirmation that cheaper options have been tried first.

Quartz Health Solutions: A Brief Overview

Quartz is a regional insurer headquartered in Madison, Wisconsin, offering individual, family, and employer-sponsored plans across Wisconsin and parts of Illinois, Iowa, and Minnesota. It operates under the UnityPoint Health and UW Health network umbrellas.

Formulary structure

Quartz uses a five-tier formulary. Dupixent sits at Tier 4 (preferred specialty) or Tier 5 (non-preferred specialty) depending on the specific plan. Members on high-deductible health plans pay full negotiated cost until the deductible is met, then coinsurance. The formulary is updated quarterly; always verify the current tier at the Quartz drug search tool or call the pharmacy benefits number on your insurance card.

Covered indications under Quartz

Quartz generally aligns coverage with FDA-approved labeling [2], meaning it will authorize Dupixent for:

• Moderate-to-severe atopic dermatitis (age 6 months and older)
• Moderate-to-severe asthma with an eosinophilic phenotype or oral corticosteroid dependence (age 6 and older)
• Chronic rhinosinusitis with nasal polyps (CRSwNP, adults)
• Eosinophilic esophagitis (EoE, age 12 and older, weight at least 40 kg)
• Prurigo nodularis (adults)
• Moderate-to-severe COPD with eosinophilic inflammation (adults, approved June 2024)

Off-label use is almost never covered without an extraordinary case review.

Prior Authorization Requirements for Dupixent Under Quartz

Prior authorization is not optional. Every Quartz commercial and marketplace plan requires PA before the pharmacy or specialty pharmacy will dispense Dupixent. The prescribing clinician initiates the request, not the patient.

What the PA form typically requires

Based on standard Quartz specialty drug PA criteria (updated annually), the submission must document:

1. Confirmed diagnosis supported by ICD-10 code and clinical notes (e.g., L20.9 for atopic dermatitis)
2. Disease severity consistent with the approved indication (for atopic dermatitis: IGA score of 3 or 4, or EASI score above 16, or SCORAD above 25)
3. Inadequate response or contraindication to conventional therapy. For atopic dermatitis this typically means a documented trial of a medium-to-high-potency topical corticosteroid for at least 4 weeks.
4. Specialist involvement. Dermatology, allergy/immunology, pulmonology, or gastroenterology notes depending on the indication.
5. Current weight and age for pediatric patients (dupilumab dosing is weight-based in children) [4].

Incomplete submissions are the leading cause of denial. Ask your prescriber's office to attach the clinical chart notes directly rather than relying on the checkboxes alone.

Timelines

Wisconsin law requires health insurers to issue a standard PA decision within 3 business days of receiving a complete request. Expedited requests (when standard timelines could seriously jeopardize health) must be decided within 72 hours. Quartz's member services line (608-828-1301 for commercial plans) can confirm whether a request was received and is complete.

Step therapy for atopic dermatitis specifically

For moderate-to-severe atopic dermatitis, Quartz step therapy typically requires:

• At least one mid-to-high potency topical corticosteroid (e.g., triamcinolone 0.1% or clobetasol 0.05%) for a minimum of 4 continuous weeks
• Documentation of inadequate response (residual IGA of 2 or higher) or a contraindication (skin atrophy, periocular or genital involvement precluding potent steroid use)

Patients who have already tried topical calcineurin inhibitors (tacrolimus 0.1% ointment) or crisaborole may have an easier path if those trials are documented in the chart. The step therapy does not require trials of oral immunosuppressants (cyclosporine, methotrexate) for most commercial Quartz plans, which aligns with AAD guidelines recommending against routine systemic immunosuppressant use before dupilumab in adults [5].

How to Submit a Prior Authorization and Maximize Approval Odds

The prescribing office submits the PA. Patients should be aware of the process so they can follow up and provide supporting documentation quickly.

Step-by-step PA submission process

1. The prescriber's office contacts Quartz by fax (PA fax number is on the provider portal at quartz.com/providers) or through the electronic PA system (CoverMyMeds or Availity).
2. The office submits clinical notes, the PA form, and the specific Dupixent NDC being requested (300 mg/2 mL auto-injector pens, NDC 0024-5916-02 for the two-pen carton is the most common commercial presentation).
3. Quartz routes the request to its pharmacy benefit manager (PBM) for specialty drugs. Quartz uses OptumRx as its PBM for many plans; confirm on your card.
4. A clinical pharmacist or medical director reviews the case. They may request additional records within 24 hours.
5. The approval or denial letter is sent to the prescriber and to the member.

Tips that improve first-pass approval rates

• Include objective severity scoring (IGA, EASI, or SCORAD) in the notes, not just "patient has severe eczema."
• Attach photos if your practice uses teledermatology platforms; photos can substitute for in-person severity documentation.
• State explicitly why lower-cost alternatives are inadequate or contraindicated. Ambiguity gives reviewers a reason to request more information, adding days to the decision.
• Confirm the exact plan name on the member's ID card before submitting. Quartz offers multiple plan types (HMO, POS, EPO) and PA criteria can differ slightly between them.

What Happens If Quartz Denies Dupixent Coverage

Denial does not mean the end. Most first-time denials for Dupixent are for administrative reasons (missing documentation) rather than a clinical determination that the drug is not medically necessary.

Level 1: Internal appeal

File a written internal appeal within 180 days of receiving the denial notice (Wisconsin law, Wis. Stat. § 632.83). Submit:

• A letter from the prescriber explaining the medical necessity
• Updated clinical notes and scoring
• Peer-reviewed literature supporting use (the LIBERTY AD SOLO 1/2 data [3] and the LIBERTY AD CHRONOS trial data are directly relevant)
• Any specialist letters

Quartz must decide a standard internal appeal within 30 days. Expedited appeals must be decided within 72 hours.

Level 2: Independent external review

If the internal appeal fails, Wisconsin members have the right to an independent external review through the Wisconsin Office of the Commissioner of Insurance (OCI). The external reviewer is a board-certified specialist in the relevant field. External reviewers overturn insurer decisions in approximately 40% of specialty drug cases nationally, according to data compiled by the Kaiser Family Foundation [6].

Level 3: State complaint

If external review fails, a formal complaint to the Wisconsin OCI (oci.wi.gov) is the next step. This rarely reverses a clinical denial but can identify procedural violations that lead to a re-review.

Dupixent Cost Assistance When Coverage Is Denied or Incomplete

Even with Quartz coverage, out-of-pocket costs on a specialty tier can be substantial. Multiple programs exist to fill that gap.

Sanofi/Regeneron MyWay savings program

Commercially insured patients who meet eligibility criteria may pay as little as $0 per month through the Dupixent MyWay savings card (dupixent.com/savings). The program covers up to $13,000 per year in out-of-pocket costs. Medicare and Medicaid beneficiaries are not eligible for manufacturer cards, but see below.

Patient assistance program (PAP)

Patients without insurance or whose insurance denies coverage may qualify for free Dupixent through Sanofi's patient assistance program if household income is at or below 600% of the federal poverty level. The application is managed through dupixent.com/support or by calling 1-844-DUPIXENT.

Wisconsin Medicaid and BadgerCare Plus

Wisconsin Medicaid (ForwardHealth) covers Dupixent for qualifying indications under its preferred drug list, but requires PA and typically a dermatologist or allergist attestation. BadgerCare Plus members should contact their managed care organization directly, as PA criteria may differ from commercial Quartz plans.

Specialty pharmacy programs

Quartz routes Dupixent through a contracted specialty pharmacy (often Optum Specialty Pharmacy or Accredo). These pharmacies have on-staff reimbursement specialists who can often identify additional assistance programs and handle PA re-submissions on the prescriber's behalf.

The Pharmacology of Dupixent: What Quartz's Medical Directors Review

Quartz's pharmacy and therapeutics (P&T) committee reviews dupilumab's clinical evidence annually. Understanding what that committee looks at helps explain the PA criteria.

Mechanism of action

Dupilumab binds the IL-4 receptor alpha subunit, blocking both IL-4 and IL-13 signaling. Both cytokines drive type 2 inflammation, which underlies atopic dermatitis, eosinophilic asthma, CRSwNP, and EoE. Blocking this shared receptor explains the drug's efficacy across multiple type 2 inflammatory conditions [1].

Key efficacy data the P&T committee weighs

The LIBERTY ASTHMA QUEST trial (N=1,902) showed dupilumab 200 mg or 300 mg every two weeks reduced severe asthma exacerbations by 47.7% compared with placebo over 52 weeks in patients with baseline eosinophils of at least 300 cells per microliter (P<0.001) [7]. For CRSwNP, the SINUS-24 and SINUS-52 trials showed significant reductions in nasal polyp score and nasal congestion versus placebo [8]. For EoE, the LIBERTY EoE TREET trial (N=81 in Part A) showed histologic remission (fewer than 6 eosinophils per high-power field) in 47.4% of dupilumab-treated patients versus 2.6% with placebo at week 24 [9].

Safety profile

Dupilumab's most common adverse events are injection-site reactions (occurring in about 8 to 10% of patients) and conjunctivitis (occurring in about 10% of atopic dermatitis patients, less common in other indications). Unlike cyclosporine, it carries no nephrotoxicity risk and requires no routine laboratory monitoring beyond clinical assessment [1]. That safety profile is favorable compared with older systemic options, which P&T committees typically weigh when evaluating step-therapy requirements.

Pediatric Coverage Under Quartz for Dupixent

Dupixent's pediatric approvals have expanded significantly. The FDA approved dupilumab for atopic dermatitis in children aged 6 months to 5 years in May 2022 [4], making it one of the few biologics approved for infants with this condition.

Age-specific PA requirements

For pediatric patients, Quartz PA forms require:

• Weight documentation (dosing is 200 mg or 300 mg every 4 weeks for children 6 months to 5 years, depending on weight)
• Confirmation of diagnosis by a pediatric dermatologist or allergist in most plans
• Documentation of topical corticosteroid failure appropriate for the child's age and affected body surface area

Pediatric cases that involve facial or periocular involvement have a strong medical necessity argument because potent topical steroids are contraindicated near the eyes, reducing the step-therapy burden in practice.

Biosimilars and Future Coverage Considerations

No FDA-approved dupilumab biosimilar existed as of January 2025, meaning Dupixent faces no direct biosimilar competition yet. The earliest possible biosimilar entry, based on patent expiry timelines, is estimated around 2031. When biosimilars do arrive, Quartz and other payers will likely shift coverage criteria to prefer the biosimilar and require additional PA documentation to continue with branded dupilumab.

The FDA's Biologics Price Competition and Innovation Act (BPCIA) pathway governs biosimilar approval [10]. Patients and prescribers should monitor the FDA's biosimilar product database for any new applications.

Quartz Plan Types and How Coverage Differs

Not all Quartz plans are identical. The PA criteria above represent typical commercial Quartz plans, but the following nuances apply:

Employer-sponsored self-funded plans

Some large employers that use Quartz as a third-party administrator (TPA) self-fund their health benefits. Self-funded plans are governed by ERISA, not Wisconsin state insurance law. This means Wisconsin's 72-hour expedited appeal requirement may not apply. Check the Summary Plan Description (SPD) for the employer's specific PA and appeal timelines.

ACA marketplace plans (Quartz Individual)

Quartz individual marketplace plans follow Wisconsin state law and ACA requirements. The essential health benefit (EHB) rules require coverage of prescription drugs in each therapeutic class. Dupixent, as the only FDA-approved IL-4/IL-13 blocker, arguably falls within the dermatology/immunology therapeutic class, which strengthens an appeal argument if denied on formulary grounds.

Medicare Advantage (Quartz Medicare Advantage)

Medicare Advantage plans that include Part D drug coverage handle Dupixent differently. It appears on the Part D formulary as a specialty drug. Low-Income Subsidy (LIS/Extra Help) beneficiaries pay a fixed copay of roughly $11.20 per month for specialty drugs in 2024 under the LIS cap. The Inflation Reduction Act's $2,000 Part D out-of-pocket cap, effective January 2025, dramatically reduces exposure for Medicare members needing Dupixent [11].

Frequently Asked Questions