Prior authorization criteria are established by our Quartz Pharmacy & Therapeutics Committee with input from physicians and consideration of the current medical literature. These medications are identified within the Formulary and have a "PA" following the drug name. PA criteria for pharmacy benefit medications can be found by following the formulary link
Medications that are given in the doctor's office that require a Prior Authorization can be found here:
If a medication is required that is not routinely covered, the provider may present medical evidence to obtain an individual patient exception by submitting a prior authorization request.
Prior authorization forms should be completed and directed to:
2651 Midwest Drrive
Onalaska, WI 54650
Fax: (608) 881-8398
Telephone: (800) 362-3310 or (608) 644-3430
To obtain authorization for coverage of a non-covered prescription drug or device in an urgent care situation, the provider or pharmacy may contact our Pharmacy Department via telephone to obtain authorization within a medically appropriate time frame, but not to exceed 24 hours.
Drug Prior Authorization Process
Certain prescription drugs, as determined by the Quartz Pharmacy & Therapeutics Subcommittee, require prior authorization, or may be subject to quantity limits or step therapy. Prior authorization criteria are established with input from physicians and consideration of current medical literature.
Provider authorization forms need to be completed by the healthcare provider and directed, by fax or mail, to Quartz Pharmacy Management.
Within 72 hours of receipt of a request, the member will be notified by phone, or in writing, of the prior authorization determination. If a provider fails to follow the health plan’s procedures for filing the prior authorization, the provider will be notified within five days upon receipt of the request.
To obtain coverage of a prescription requiring prior authorization in an urgent care situation, providers may contact us.
The time frame for an urgent review and determination will not exceed 24 hours from receipt of the request.
Quartz provides the practitioner with information to understand and decide whether to appeal a decision to deny coverage. The following information is included in all denial notices:
You may obtain a copy of the criteria, clinical guidelines, or benefit provisions used for making a decision. Please contact us, or send your request to us at the address listed above. Quartz is staffed with pharmacists who are able to discuss medical necessity decisions. In the event a pharmacist is unavailable, our medical director or an associate medical director can address questions regarding determinations.