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Medication Prior Authorization

Medication Prior Authorization List

Monthly updates will be made to the Prior Authorization List. Providers are reminded to review the Prior Authorization List on a regular basis for any updates or changes which may be made. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Applicable Prior Authorization Criteria

Prior authorization is required for clinic-administered medications in the Medication List. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Request Form to Quartz at (888) 450-4711.

The patient has pharmacy AND medical benefit coverage through Quartz.

QUARTZ PHARMACY AND MEDICAL BENEFIT COVERAGE

The patient has ONLY medical benefit coverage through Quartz.

QUARTZ MEDICAL BENEFIT COVERAGE ONLY

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