Medication Prior Authorization

• All medications with Prior Authorization / Restricted Status require Prior Authorization for coverage
• Restricted medications may be Preferred or Non-preferred. The formulary status will determine the copayment if the prior authorization request is approved
• Many drug benefits associated with Quartz’s High Deductible Health Plans (HDHPs) require prior authorization for non-preferred medications
• If a request is Urgent, there is a 5 day emergency supply option available as well as a new member drug supply option available.
• For urgent requests, complete the "Print and Fax" form (see button) and fax it directly to the number on the form. The request must provide clinical documentation FROM THE PRESCRIBER with the PRESCRIBER'S SIGNATURE stating why the request is urgent. Requests will only be treated as urgent for clinical reasons. Without documentation to support the urgency of the request, it may be treated as a standard request (this cannot be done using the online form).
• Certain medications administered in a clinic require an approved medical prior authorization before administration would be covered under the medical benefit

The criteria for coverage of restricted medications are listed on the Medication Prior Authorization Criteria.

* Requesting Prior Authorization for Medications

• The following clinical information is needed for each request:
  • Name of drug (and J code or CPT code, if applicable) for which coverage is requested
  • Diagnosis
  • Names of ​preferred medications that have been tried and trial dates
  • Problems with ​preferred medications, such as lack of effectiveness or adverse effects
  • Rationale for using the ​non-preferred or restricted medication
• A clinical pharmacist will review the request using Quartz’s prior authorization criteria to determine coverage
• Requestors and patients will be notified of the decision by fax and mail, respectively
• Prior authorization approval notifications will be sent to the patient’s pharmacy if the pharmacy name is included on the request
• Practitioners and patients may appeal a determination by calling Customer Service at (800) 362-3310 and notifying the representative that you wish to appeal
• Quartz makes decisions on most standard prior authorization requests within two business days, but if additional information is necessary it may take as long as 15 calendar days

Requesting Prior Authorization for Medications*

To Request coverage of a medication requiring prior authorization, complete the Medication Prior Authorization Request form and submit online or fax to the number that appears on the form.

Requests can also be initiated via telephone but for most expedient review, forms should be completed by prescribers and submitted via SECURE electronic submission or via fax.

Download and print
Medication Prior Authorization Request Form

Please click the button below to open a PDF document of Quartz’s medication prior authorization criteria for coverage. Use “control-F” to open a search box in the document and type the drug name you are looking for. Press “enter” to scroll through the document as drugs may be listed more than once.