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Medication Prior Authorization

Medication Prior Authorization List

Monthly updates will be made to the Prior Authorization List. Providers are reminded to review the Prior Authorization List on a regular basis for any updates or changes which may be made. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Applicable Prior Authorization Criteria

Prior authorization is required for clinic-administered medications listed below. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Request Form to Quartz at (888) 450-4711.

The patient has pharmacy AND medical benefit coverage through Quartz.

QUARTZ PHARMACY AND MEDICAL BENEFIT COVERAGE

The patient has ONLY medical benefit coverage through Quartz.

QUARTZ MEDICAL BENEFIT COVERAGE ONLY

Medication List

  • Abatacept IV (Orencia)*
  • Adalimumab (Humira)
  • Aducanumab (Aduhelm) – Not covered (except for FEHB)
  • Afamelanotide acetate (Scenesse)
  • Agalsidase beta (Fabrazyme)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Amivantamab (Rybrevant)
  • Anakinra (Kineret)
  • Anti-Inhibitor (Feiba NF)
  • Asfotase (Strensiq)
  • Atezolizumab (Tecentriq)
  • Avelumab (Bavencio)
  • Belantamab (Blenrep)
  • Belimumab (Benlysta) infusion
  • Benralizumab (Fasenra)*
  • Bevacizumab (Avastin) – only covered if intravitreal injection; biosimilars covered without PA
  • Bezlotoxumab (Zinplava)
  • Botulinum toxin products (Xeomin, Botox, Dysport, Myobloc, Jeuveau)
  • Brexanolone (Zulresso)
  • Burosumab (Crysvita)
  • C1 esterase inhibitor (Berinert, Haegarda, Cinryze, Ruconest)
  • Calaspargase (Asparlas)
  • Canakinumab (Ilaris)*
  • Caplacizumab (Cablivi)
  • Carfilzomib (Kyprolis)
  • CAR-T cell therapy (Abecma, Breyanzi, Kymriah, Tecartus, Yescarta) – reviewed by Medical Management
  • Casimersen (Amondys 45) – not covered (except for FEHB benefits)
  • Cemiplimab (Libtayo)
  • Cerliponase alfa (Brineura)
  • Certolizumab (Cimzia)
  • Corticotropin (Acthar H.P.)
  • Crizanlizumab-tmca (Adakveo)
  • Daratumumab, Daratumumab-Hyaluronidase (Darzelex, Darzelex Faspro)
  • Denosumab (Prolia, Xgeva)*
  • Dostarlimab (Jemperli)
  • Dupilumab (Dupixent)*
  • Durvalumab (Imfinzi)
  • Ecallantide (Kalbitor)
  • Eculizumab (Soliris)*
  • Edaravone (Radicava)
  • Elapegademase (Revcovi)
  • Elotuzumab (Empliciti)
  • Emapalumab (Gamifant)
  • Emicizumab (Hemlibra)
  • Enfortumab vedotin (Padcev)
  • Epoetin alfa (Epogen, Procrit) – not covered; use biosimilar, no prior authorization required
  • Eptinexumab-JJMR (Vyepti)
  • Epoprostenol (Veletri)*
  • Eteplirsen (Exondys 51) – not covered (except for FEHB benefits) 
  • Esketamine (Spravato)
  • Etanercept (Enbrel)
  • Evinacumab (Evkeeza)
  • Factor IX (Alphanine SD, Aprolix, Bebulin VH, Benefix RT, Idelvion, Ixinity, Mononine, Profilnine, Rixubis, Rebinyn)
  • Factor VII (Humate-P, NovoSeven RT, Sevenfact)
  • Factor VIII (Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemofil, Jivi, Koate, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha, Vonvendi)
  • Factor X (Coagadex)
  • Factor XIII (Corifact, Tretten)
  • Filgrastim (Neupogen) – not covered; use biosimilar, no prior authorization required
  • Fosdenopterin (Nulibry)
  • Givosiran (Givlaari)
  • Golimumab IV (Simponi) – not covered
  • Golodirsen (Vyvondys 53) – not covered (except for FEHB benefits) 
  • GNRH agonist ( leuprolide, Lupron, Fensolvi, Vantas, Supprelin LA) – for use in gender dysphoria
  • Guselkumab (Tremfya)
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine (Gardasil-9) – for ages outside of 9-45 years
  • Hydroxyprogesterone caproate (Makena)
  • Icatibant (Firazyr)
  • Immune Globulin Products (Asceniv, Bivigam, Carimune NF, Cutaquig, Cuvitru, Flebogamma DIF, GamaSTAN, Gammagard, Gammagard S/D Less IgA, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panzyga, Privigen, Xembify)
  • Inebilizumab-cdon (Uplizna)
  • Infliximab (Remicade) – not covered; use biosimilar*
  • Infliximab biosimilar (Renflexis, Inflectra, Ixifi, Avsola)*
  • Inotersen (Tegsedi)
  • Interferon alfa-2b (Intron A)
  • Interferon alfa N3 (Alferon A)
  • Interferon beta-1a (Rebif, Avonex)
  • Interferon gamma 1b (Actimmune)
  • Iobenguane iodine (Azedra)
  • Ipilimumab (Yervoy)
  • Lanadelumab (Takhzyro)
  • Letermovir (Prevymis)
  • Loncastuximab (Zynlonta)
  • Lumasiran (Oxlumo)
  • Luspatercept (Reblozyl)
  • Lutetium Lu 177 dotatate (Lutathera)
  • Margetuximab (Margenza)
  • Mepolizumab (Nucala)*
  • Mogamulizumab (Poteligeo)
  • Moxetumomab pasudotox-tdfk (Lumoxiti)
  • Natalizumab (Tysabri)*
  • Naxitamab (Danyeiza)
  • Necitumumab (Portrazza)
  • Nivolumab (Opdivo))
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)*
  • Omalizumab (Xolair)*
  • Onasemnogene (Zolgensma)
  • Palifermin (Kepivance)
  • Palivizumab (Synagis)*
  • Parathyroid hormone (Natpara)
  • Patisiran (Onpattro)
  • Pegcetacoplan (Empaveli)
  • Pegfilgrastim (Fulphila, Udenyca, Ziextenzo)
  • Pegfilgrastim (Neulasta) – not covered
  • Peginterferon alfa-2a (Pegasys)
  • Peginterferon alfa-2b (Pegintron, Sylatron)
  • Peginterferon beta-1a (Plegridy)
  • Pegloticase (Krystexxa)*
  • Pembrolizumab (Keytruda)
  • Polatuzumab (Polivy)
  • Ramucirumab (Cyramza)
  • Ravulizumab (Ultomiris)*
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rituximab (Rituxan) – not covered; biosimilars covered without prior authorization
  • Romiplostim (Nplate)
  • Romosozumab-aqqg (Evenity)*
  • Sacituzumab Govitecan (Trodelvy)
  • Sebelipase alfa (Kanuma)
  • Secukinumab (Cosentyx)
  • Siltuximab (Sylvant)
  • Somatropin (Genotropin, Humatrope, Norditroin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive)
  • Tafasitamab (Monjuvi)
  • Tagraxofusp (Elzonris)
  • Teprotumumab (Tepezza)
  • Testosterone injection, implant (Aveed, Testopel, cypionate, enanthate, Depo-Testosterone, Delatestryl)
  • Tildrakizumab (Illumya)*
  • Tocilizumab (Actemra)
  • Trabectedin (Yondelis)
  • Trastuzumab (Herceptin) – not covered; biosimilar covered without prior authorization
  • Treprostinil (Remodulin)* – not covered; use generic
  • Trilaciclib (Cosela)
  • Ustekinumab (Stelara)*
  • Vedolizumab (Entyvio)*
  • Viltolarsen (Viltepso) – not covered (except for FEHB benefits)
  • Voretigene neparvovec-RZYL (Luxturna)
  • Xofigo (Radium 223 Dichloride)
  • Zoster vaccine (Shingrix) – for ages < 50 years
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with the amount billed > $2,500

*These drugs are included in Quartz’s Vendor Solution Drug Program, which includes drugs administered by a physician or clinician.

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