Member Prior Authorization Resources:
General List

• Experimental and Investigational Treatments 
• In-home Therapy
• Partial Hospital Program (PHP)
• Residential Treatment
• Transcranial Magnetic Stimulation (TMS)
• Vagus Nerve Stimulation

All equipment rentals and any purchased items in excess of $500 in billed charges require prior authorization.

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 Hospital (LTACH)
• Psychiatric ​Admissions
• Skilled ​Nursing ​Facility/Swing ​Bed

Prior authorization is required for the clinic-administered medications listed below:

• View the clinic administration medication list
• View the medical benefit PA criteria library
• View additional resources for medical benefit medications

For patients that have pharmacy coverage through Quartz, prior authorization is required for the prescription medications listed in the prescription benefit PA criteria library.

Quartz pharmacy criteria – Large Group – Small Group/Individual

Note: The following procedures must receive prior authorization before they can be scheduled.

• Bariatric Surgery
• Gender Reassignment Surgical Procedures
• 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
• Orthognathic Surgery
• Orthopedic Procedures (including artificial cervical and lumbar disc surgery and OATS procedures)
• Panniculectomy
• Removal of Port Wine Stains and Hemangiomas
• Rhinoplasty and Septorhinoplasty
• Scar Revision and Repair (cosmetic procedures are excluded)
• Surgical Treatment of Obstructive Sleep Apnea
• Temporomandibular Joint Disease Surgical Treatment
• Transplants, including donor and other related charges (excludes corneal, except for artificial corneal transplants)

• Ambulance Services (non-emergent/urgent) 
• CAR T Cell Therapy 
• Custom Shoes and Custom-molded Orthotics (including orthopedic shoes) 
• Experimental and Investigational Treatments 
• Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)
• Genetic Testing 
• Home Health Care (including home infusion services and other in-home therapy services)
• Hospice Care 
• Hyperbaric Oxygen Therapy 
• Palliative Care
• Proton Beam Therapy
• Treatment of Urinary and Fecal Incontinence
• Bioengineered Skin Substitutes