Health Care Practitioners
Prior Authorization List

Monthly updates will be added 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 added. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Durable Medical Equipment

  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac defibrillator (external only)
  • Continuous glucose monitors
  • Continuous passive motion machines
  • CPAP, BiPAP rental and purchase
  • Custom shoes and custom-molded foot orthotics (limited benefit) includes orthopedic shoes
  • Cystic Fibrosis vests
  • Dynamic Orthotic Cranioplasty (DOC) bands
  • Home monitoring devices
  • Hospital beds and related supplies
  • Insulin pumps
  • Life sustaining nutritional therapies
  • Light therapy (UVB) for in-home use
  • Mechanical stretching devices
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • TENS and other eStim devices
  • Walk-aid devices (electronic or eStim)
  • Wheelchairs and motorized scooters
  • Wound therapy (Advanced), including vac therapy, wound warming devices and artificial skin

Experimental and Investigational Treatments


Genetic Testing including Pharmacogenetics Testing


Home Health Care including home infusion services and other in-home therapy services


Hospice Care


Inpatient Admissions

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
  • Psychiatric admissions
  • Skilled nursing facility / swing bed

Other Services

  • Corneal Cross-linking
  • Day treatment
  • External Extended Electrocardiographic recording (ZIO Patch)
  • Intensive Outpatient Program (IOP)
  • Left Ventricular Assist Devices or LVAD’s for heart failure
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Residential treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless / remote heart failure monitoring devices (CardioMems)

Out-of-Network services or supplies


Pharmacy / Medications

Prior authorization is required for the clinic-administered injectible medications. Practitioners must submit a prior authorization request via MyPlanTools or fax a Medication Prior Authorization Request Form to Quartz at (888) 450-4711.
  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Buprenorphine (Probuphine) implant
  • Cankinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Cerliponase alfa (Brineura) ​
  • Daratumumab (Darzalex)
  • Denosumab (Prolia, Xgeva)
  • Dupilumab (Dupixent) ​
  • Eculizumab (Soliris)
  • Edaravone (Radicava)​
  • Elotuzumab (Empliciti)
  • Eteplirsen (Exondys) not covered – experimental
  • Golimumab IV (Simponi)
  • GNRH agonist ( leuprolide, Lupron, Vantas, Supprelin LA) for use in gender dysphoria
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine for ages outside of 9-26 years (Gardasil)
  • Hydroxyprogesterone caproate (Makena)
  • Incobotulinum (Xeomin)
  • Infliximab (Remicade, Inflectra)
  • Mepolizumab (Nucala)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palivizumab (Synagis)
  • Pegfilgrastim (Neulasta)
  • Renflexis (Infliximab-Abda)​
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Testosterone Cypionate (Depo-Testosterone)
  • Testosterone Enanthate (Testosterone Enanthate)
  • Testosterone Implant (Testopel)
  • Testosterone Undecanoate (Aveed)
  • Tocilizumab (Actemra)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Xofigo (Radium 223 Dichloride)
  • Zinplava (Bezlotoxumab)
  • Zoster vaccine for age <60 years (Zostavax)
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $2500

Surgical Procedures

The following procedures must be prior authorized before they are scheduled.
  • Abortions including multi-fetal reductions
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Implantable Nerve Stimulators
  • Laser re-surfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser treatment of actinic keratosis or other benign skin lesions
  • Endoscopic procedures for Reflux Management
  • Orthopedic Procedures: Artificial cervical and lumbar disc surgery
  • Panniculectomy (tummy tuck)
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and other repair of scars
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical treatment
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Uvuloplasty, Uvulopalatoplasty, Somnoplasty, LAUP and other treatments for snoring or airway obstruction
  • Varicose vein or spider vein procedures including sclerotherapy, radiofrequency ablation, vein stripping and ligation

Therapies

  • Biofeedback (only covered for spastic torticollis or headache)
  • Hyperbaric Oxygen Therapy
  • Prolotherapy
  • TheraSphere / Sir-Spheres Treatment
If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within MyPlanTools for providers or MyChart for members or call (800) 362-3310.