Medication Prior Authorization List

Monthly updates will be added 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 added.

Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Prior authorization is required for clinic-administered medications listed below. Practitioners must submit a prior authorization request via MyPlanTools or fax a Medication Prior Request Form to Quartz at (888) 450-4711.

Applicable Prior Authorization Criteria

View the applicable PA Criteria by clicking the appropriate button below.

The patient has pharmacy AND medical benefit coverage through Quartz.

The patient has ONLY medical benefit coverage through Quartz.

  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • Agalsidase beta (Fabrazyme)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Anti-Inhibitor (Feiba NF)
  • Atezolizumab(Tecentriq)
  • Avelumab (Bavencio)
  • Belimumab (Benlysta) infusion
  • Benralizumab (Fasenra)
  • Buprenorphine (Probuphine) implant
  • C1 esterase inhibitor (Berinert)
  • C1 esterase inhibitor (Cinryze)
  • C1 esterase inhibitor (Haegarda)
  • C1 esterase inhibitor (Ruconest)
  • Cankinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Cemiplimab-rwlc (Libtayo)
  • Cerliponase alfa (Brineura) not covered - experimental
  • Corticotropin (Acthar H.P.)
  • Daratumumab (Darzalex)
  • Denosumab (Prolia, Xgeva)
  • Dupilumab (Dupixent)
  • Durvalumab (Imfinzi)
  • Ecallantide (Kalbitor)
  • Eculizumab (Soliris)
  • Edaravone (Radicava)
  • Elotuzumab (Empliciti)
  • Eteplirsen (Exondys) not covered – experimental
  • Factor IX (Alphanine SD, Aprolix, Bebulin VH, Benefix RT, Idelvion, Ixinity, Mononine, Profilnine, Rixubis, Rebinyn)
  • Factor VII (Humate-P, NovoSeven RT)
  • Factor VIII (Advate, Adynovate, Afstyla, Alphanate, Eloctate, Helixate FS, Hemofil, Jivi, Koate, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Recombinate, Wilate, Xyntha)
  • Factor X (Coagadex)
  • Factor XIII (Corifact)
  • Golimumab IV (Simponi)
  • GNRH agonist ( leuprolide, Lupron, Vantas, Supprelin LA) for use in gender dysphoria
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine for ages outside of 9-26 years (Gardasil)
  • Hydroxyprogesterone caproate (Makena)
  • Icatibant (Firazyr)
  • Incobotulinum (Xeomin)
  • Infliximab (Remicade, Renflexis, Inflectra)
  • Iobenguane iodine (Azedra)
  • Ipilimumab (Yervoy)
  • Letermovir (Prevymis)
  • Lutetium Lu 177 dotatate (Lutathera)
  • Mepolizumab (Nucala)
  • Mogamulizumab (Poteligeo)
  • Moxetumomab pasudotox-tdfk (Lumoxiti)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Necitumumab (Portrazza)
  • Nivolumab (Opdivo))
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palifermin (Kepivance)
  • Palivizumab (Synagis)
  • Patisiran (Onpattro)
  • Pegfilgrastim (Fulphila, Neulasta)
  • Pegloticase (Krystexxa)
  • Pembrolizumab (Keytruda)
  • Ramucirumab (Cyramza)
  • Ravulizumab-cwvz (Ultomiris)
  • Renflexis (Infliximab-Abda)
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Siltuximab (Sylvant)
  • Tagraxofusp (Elzonris)
  • Testosterone Cypionate (Depo-Testosterone)
  • Testosterone Enanthate (Testosterone Enanthate)
  • Testosterone Implant (Testopel)
  • Testosterone Undecanoate (Aveed)
  • Tocilizumab (Actemra)
  • Trabectedin (Yondelis)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Voretigene neparvovec-RZYL (Luxturna)
  • Xofigo (Radium 223 Dichloride)
  • Zinplava (Bezlotoxumab)
  • Zoster vaccine for age <50 years (Shingrix)
  • Zoster vaccine for age <60 years (Zostavax)
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $2500

Questions

If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within MyPlanTools for providers or MyChart for members or call (800) 362-3310.