Gundersen Part B medications requiring prior authorization

Prior authorization is required for the clinic-administered medications listed in the Part B prior authorization medication list below. You’ll also find the Part B Step Therapy and Part B Prior Authorization Criteria for your review. Monthly updates may occur to the prior authorization list, so it is important to regularly review the Part B prior authorization medication list below for any updates or changes.

• • Part B Prior Authorization Medication List

• • Part B Step Therapy Criteria

• • Part B Prior Authorization Criteria (by clicking this link you will be leaving the Quartz Medicare Advantage website)
    • • Follow the directions to log in to the portal
    • • Expand the Ambulatory Care and Behavioral Health Care menus
    • • Search by pressing Ctrl + F for the criteria ID or title (as noted in the Part B Prior Authorization Medication List)

Important reminders

• • Practitioners must submit a prior authorization request via My Quartz Tools or fax us a Clinic-Administered Medication Prior Authorization Request Form.

• • Medicare Drug Coverage Policies apply (Local Coverage Determinations (LCD), National Coverage Determinations (NCD), etc), but do not require prior authorization (unless included in the Part B prior authorization medication list above).

• • For the most up-to-date Medicare policies and coverage, search the Medicare Coverage Database (by clicking this link you will be leaving the Quartz Medicare Advantage website).

• • Medications that are usually self-administered are excluded from coverage under Medicare Part B
    (Per the Self-Administered Drug Exclusion List (A53022)).

Questions?

Please contact Customer Success with specific code information if you need help determining if an item or service requires prior authorization.