To see which prescription drugs need Prior Authorization check your formulary.
Does your doctor or nurse give you your medicine (through an IV, for example)? If so, you may need an approved Prior Authorization first. Be sure to check the Medication Prior Authorization List. If the medicine is on that list, you need to get a Medication Prior Authorization.
Your clinic staff can help you.
You or your doctor can fill out a Drug Prior Authorization Request Form (PA Request). Or your designated representative can fill it out. You can send it in via the fax, mail, or telephone.
It makes the most sense to have your doctor / nurse or pharmacist fill out the PA Request for you. They will have your medical history information that is needed. That means the PA Request can be reviewed more quickly.
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.
Prior authorization forms should be completed and mailed to:
2651 Midwest Drive
Onalaska, WI 54650
Faxed to: (608) 881-8398
Called in by the clinician at: (800) 362-3310 or (608) 644-3430
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.
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.
As a member of the Quartz, you may initiate an exception request process. For your convenience, we have prepared a form that you may complete and submit on-line, by fax or by mail to us. To complete the drug exception request click here.
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.