Prior Authorization List

The following is not an all-inclusive list. Updates are periodically made to the Prior Authorization list.

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

Durable Medical Equipment

  • Airway Clearance Devices
  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac defibrillator (external only)
  • Continuous glucose monitors
  • Continuous passive motion machines
  • CPAP, BiPAP (rental and purchase)
  • Custom shoes and custom-molded foot orthotics (limited benefit) includes orthopedic shoes
  • Dynamic Orthotic Cranioplasty (DOC) bands
  • Electric Tumor Treatment Fields (TTF) Device (Optune®)
  • Home monitoring devices
  • Home Phototherapy (UVB) Light Devices for treatment of Psoriasis
  • Hospital beds and related supplies
  • Insulin pumps
  • Life sustaining nutritional therapies
  • Mechanical stretching devices
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • Spinal Traction Devices
  • Standing Frame / Stander
  • TENS and other e-Stim devices
  • Walk-aid devices (electronic or e-Stim)
  • Wheelchairs and motorized scooters

Experimental and Investigational Treatments

Genetic Testing including Pharmacogenetics Testing

Home Health Care including home infusion services and other in-home therapy services

Hospice Care


Inpatient Admissions

(Note: Urgent / emergent hospital admissions require notification at the time of admission. Elective hospital admissions require prior authorization before admission and notification when admitted.)
  • Hospitals, acute inpatient care
  • Inpatient rehabilitation facilities
  • Long term acute care (LTACH)
  • Psychiatric admissions
  • Skilled nursing facility / swing bed

Other Services

  • Day treatment
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors / Loop Recorders)
  • Fecal Bacteriotherapy
  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Platelet-Rich Plasma (PRP) Injections
  • Residential treatment
  • Steroid Releasing Sinus Implants
  • Therasphere / Sir-Spheres Treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless / remote heart failure monitoring devices (CardioMems)

OUT-OF-NETWORK SERVICES OR SUPPLIES


Pharmacy / Medications

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

  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • 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)
  • 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, Koate, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Recombinate, Wilate, Xyntha)
  • Factor VIII recombinant (Jivi)
  • 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)
  • Letermovir (Prevymis)
  • Lutetium Lu 177 dotatate (Lutathera) 
  • Mepolizumab (Nucala)
  • mogamulizumab (Poteligeo)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Nivolumab (Opdivo))
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palivizumab (Synagis)
  • Patisiran (Onpattro)
  • Pegfilgrastim (Fulphila, Neulasta)
  • Pembrolizumab (Keytruda)
  • Renflexis (Infliximab-Abda)
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Testosterone Cypionate (Depo-Testosterone)
  • Testosterone Enanthate (Testosterone Enanthate)
  • Testosterone Implant (Testopel)
  • Testosterone Undecanoate (Aveed)
  • Tocilizumab (Actemra)
  • 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

Surgical Procedures

The following procedures must be prior authorized before they are scheduled.

  • Abortions including multi-fetal reductions
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Corneal Cross-linking
  • Endoscopic procedures for Reflux Management
  • Implantable Nerve Stimulators
  • Laser re-surfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser treatment of actinic keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
  • Orthopedic Procedures including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures and Hip Resurfacing
  • Panniculectomy
  • POEM Procedure
  • Prosthetic Urethral Lift (Urolift®)
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and repair
  • Surgical Treatment of Obstructive Sleep Apnea
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical management
  • Transcatheter Closure of Septal Defect
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Varicose vein or spider vein procedures including sclerotherapy, radiofrequency ablation, vein stripping and ligation
Therapies

  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • Extracorporeal Shockwave Therapy
  • Hyperbaric Oxygen Therapy
  • Prolotherapy

WOUND THERAPY (ADVANCED) INCLUDING NEGATIVE PRESSURE (VAC) THERAPY, NONCONTACT NORMOTHERMIC WOUND THERAPY (NNWT) AND BIOENGINEERED SKIN SUBSTITUTES