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Member Prior Authorization Resources:
Illinois List

For members who live in Illinois, we work closely with our provider owners to minimize prior authorizations as much as possible.
Please review your plan’s specific prior authorization list below.

Call Customer Success for support: (800) 362-3310

Prior authorizations under your health plan

Below is a list of in-network prior authorizations currently required under your health plan. We’re always working to minimize these requirements and regularly update this list. 

If you are out of network, you will need to contact Quartz by calling customer success for help with out of network care. Call us at (800) 362-3310.

  • Experimental and Investigational Treatments
  • In-home Therapy
  • Partial Hospital Program (PHP)
  • Residential Treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation

See your Schedule of Benefits for prior authorization requirements on DME items.

  • Elective hospital admissions require prior authorization before admission and notification when admitted
  • Hospice/Palliative Care
  • Hospitals, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long-Term Acute Care Hospital (LTACH)
  • Psychiatric Admissions
  • Skilled Nursing Facility/Swing Bed

Prior authorization is required for the clinic-administered medications listed below:

For patients that have pharmacy coverage through Quartz, prior authorization is required for the prescription medications listed in the prescription benefit PA criteria library.

Quartz pharmacy criteria – Large Group – Small Group/Individual

 

  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow Lifts
  • Cochlear Implants
  • Deep Brain Stimulation
  • Endoscopic procedures for Reflux Management (LINX)
  • Gender Affirming Surgery
  • Implantable Nerve Stimulators
  • Laser resurfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser Treatment of Actinic Keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for the Treatment of Heart Failure
  • Orthognathic Procedures
  • Orthopedic Procedures (including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures)
  • Panniculectomy
  • POP (Per-Oral Pyloromyotomy) Procedure
  • Removal of Port Wine stains and Hemangiomas
  • Rhinoplasty and Septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and repair (cosmetic procedures are excluded)
  • Surgical Treatment of Obstructive Sleep Apnea
  • Temporomandibular Joint Disease Surgical Treatment
  • Transplants including donor and other related charges (excludes Corneal, except for Artificial Corneal Transplants)
  • Varicose Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping, and Ligation)

If you are out of network, prior authorization is needed for non-emergency care received. Contact Customer Success at (800) 362-3310 for help.

  • Ambulance Services (non-emergent/urgent)
  • Biofeedback (coverage limited to the treatment of Spastic Torticollis, headache, or Pediatric Urinary Incontinence)
  • CAR T-Cell Therapy
  • Custom Shoes and Custom-molded Orthotics (including orthopedic shoes)
  • Experimental and Investigational Treatments
  • Extracorporeal Shockwave Therapy
  • Genetic Testing
  • Home Health Care (including Home Infusion Services and Other In-Home Therapy Services)
  • Hyperbaric Oxygen Therapy
  • Infertility Treatment
  • Private Duty Nursing
  • Prolotherapy
  • Proton Beam Therapy
  • Radioembolization with Yttrium 90 Microspheres (TheraSphere™/SIR-Spheres®) Treatment
  • Treatment of Urinary and Fecal Incontinence
  • Vagus Nerve Stimulation
  • Wound Therapy-Advanced, including Negative Pressure/Vac Therapy and Bioengineered Skin Substitutes

Contact us

Quartz is here to help. That’s why we make it easy to reach us.

Call Quartz Customer Success (844) 644-3455 or message us on Quartz MyChart.

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