Medication Prior Authorization

Step Therapy Program

Sometimes there are a lot of different drugs that treat the same illness. Some may cost very little and others may be very expensive, but work just as well. That’s why Quartz has the Step Therapy Program. Step Therapy means that members must try the most cost-effective medications before stepping up to a more expensive drug. Many members find the first medication very effective and never need to step up.

Step therapy medications need Prior Authorization for coverage. Every Prior Authorization Request for step therapy drugs is reviewed separately. Each drug has specific criteria for approval.

Preferred or non-preferred drugs may be included in a step therapy program.

Go to the Quartz formulary to see which drugs have a "ST". These require Prior Authorization.

Medical (General) Prior Authorization
Behavioral Health Prior Authorization

Please select the appropriate prior authorization request form below and submit to:

Quartz Behavioral Health Care Management

  • Fax (608) 471-4391

Submission instructions are included with all forms.

Initial Mental Health Request Form

AODA Initial Request Form

  • Do not use these forms to request PA for TMS. 
  • A prior authorization (PA) is only required for outpatients if the request is for services with an out-of-network provider.

Mental Health Treatment Extension Request

AODA Extension Request Form

  • Use these forms to request an extension of a previously approved request.
Transcranial Magnetic Stimulation (TMS) Request Form
  • This form is used without the Initial Mental Health Treatment Request 
Eating Disorder Supplemental Request Form
  • This form is used in addition to the Initial Mental Health Treatment Request or the Extension Mental Health Treatment Request form.

For self-funded participants, please login to MyChart to view your Prior Authorization Lists.