Medication Coverage Request Form

Prior authorization criteria available: Prior Authorization Criteria, FAQs, can be found at QuartzBenefits.com/providers
Direct questions about medication prior authorization criteria to the Quartz Pharmacy Program at 888.450.4884
To check the status of a PA request contact MedImpact Customer Service at 800.788.2949
To appeal decisions contact Quartz Customer Service at 800.362.3310 (fully insured members) or 800.805.0693 (self-funded participants)
If request is for a nonformulary drug, information must be submitted that supports that all formulary drugs on any tier will be or have been ineffective, would not be as effective as the requested drug, or would have adverse effects.

PRINT AND FAX FORM

Or fill out online form below

Step 1: Patient and Prescriber Information

Date:

Prescriber name: *

Prescriber specialty:

Prescriber Office Contact:

Prescriber Phone:Format: XXX-XXX-XXXX

Member Birth Date: *

Member Name: *

Member ID #:

Prescriber Fax: *Format: XXX-XXX-XXXX

Step 2: Diagnosis and Medication Information

Diagnosis: *

Medication Therapy: *

New

Current

Medication Name: *

Dose:

Frequency:

Duration of Therapy:

Provide the reason / clinical rationale for the request. Include relevant past medical history, allergies, labs, supporting documents / clinic notes, medication trials (including names, doses, dates, detailed outcomes, such as lack of efficacy or adverse reaction), contraindications to preferred / first line therapies, and documentation why preferred / first line therapies would be expected to not work or cause harm.

Reason: *

Urgent Request

By checking the urgent checkbox, you certify that applying the standard time frame may seriously jeopardize the patient’s life, health, or ability to regain maximum function or that the patient is undergoing a current course of treatment using a nonformulary drug. Documentation must be provided below FROM THE PRESCRIBER indicating why the request is urgent / expedited. Without documentation to support urgency, request may be treated as a standard request.

Statement supporting need for urgency:

Note: Quartz has a New Member Override which may be used if the provider is unable to clinically support the need for an urgent / expedited review as outlined above and patient is currently taking a restricted medication. This will grant a fill immediately, and allow time to complete a standard coverage request without interrupting the patient’s therapy. Call MedImpact Customer Service at (800) 788-2949 to obtain this authorization.

Step 3: For Clinic / Physician Administered Medications Only

Administering Provider Name:

Providing Facility:

Provider Phone:Format: XXX-XXX-XXXX

Facility Phone:Format: XXX-XXX-XXXX

Provider Fax:Format: XXX-XXX-XXXX

Facility Fax:Format: XXX-XXX-XXXX

Procedure Code/Description:

Fax supporting documents (clinic notes, labs, etc) to (858) 357-2582

*Indicates a required field

**Prescribers will be notified by fax and members will be notified by mail when a decision has been determined.**