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.
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.
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.