What is Medication Prior Authorization?

Some drugs must be approved by Quartz before they are covered. This process is called Prior Authorization.

To see which drugs need Medication Prior Authorization, check your plan's formulary.

You can also see your plan's Medication Prior Authorization List.

Does your doctor or nurse give you your medicine (through an IV, for example)?

If so, you may need an approved Prior Authorization first. Be sure to check the Medication Prior Authorization List for your plan. If the medicine is on that list, you need to get a Medication Prior Authorization.

Your clinic staff can help you.

How do I get a Medication Prior Authorization (PA)?

You or your doctor can fill out a Medication Prior Authorization Request (PA Request). Or your designated representative can fill it out. You can send it in via the web, fax, mail, or telephone.

It makes the most sense to have your doctor / nurse or pharmacist fill out the PA Request for you. They will have your medical history information that is needed. That means the PA Request can be reviewed more quickly.

Once the Medication PA Request Form is filled out, it has to be sent to Quartz in a secure way. 

Once Quartz gets the Medication PA Form, we make a decision as soon as possible. However, if we don’t have all the information and have to ask questions, it can take up to 15 days.

Once a decision is made, we will send a notice to you and your doctor.

If the request is URGENT, the request must:

  • Provide clinical documentation from the prescriber (doctor).
  • Describe why the request is urgent.
  • Have the prescribers' signature.

Requests will only be treated as urgent for documented clinical reasons. Otherwise the request will be processed normally.

Reviewing Requests

Medication PA Requests are reviewed by pharmacy staff using criteria set by Quartz’s Pharmacy and Therapeutic (P&T) Committee. If more information is needed, Quartz will contact your doctor or nurse.

In that case, the decision and notice may take up to 15 days.

Approved Requests

If your PA Request is approved, Quartz will cover the medication. Your copay will match the formulary and brand / generic status of the drug. You can check this by looking up the drug on your formulary.

Denied Requests

If your Prior Authorization Request is denied, Quartz will not pay for the medication. The denial notice will include the reasons for the denial.

  • If you want to talk to someone about the denial, call the Quartz Pharmacy Program at (888) 450-4884.
  • You can still buy the medication but you will have to pay the full cost.
  • You can talk to your doctor or nurse about getting a similar drug that is covered by Quartz.

Note: Prior Authorization only affects whether or not a medication is covered by Quartz.