Drug Prior Authorization Forms

Contact Pharmacy Services at (608) 260-7803, (800) 545-5015, or PPICInfo@QuartzBenefits.com

Members with an urgent life-threatening medication prior authorization request please contact Pharmacy Services directly at (608) 260-7803 or fax (608) 327-0324 Monday through Friday before 5 p.m. For assistance outside of regular business hours or holidays, please leave a detailed voicemail or submit a prior authorization form clearly marked "Urgent" or "Expedited."


Standard Prior Authorization Request: Medication PA Request Form

Online Medication Prior Authorization Request Form


Forms listed alphabetically by their brand name

A
Actemra SC (tocilizumab) - Indication Based
Acthar Gel (repository corticotropin)
Adempas (riociguat)
Amitiza (lubiprostone)
Ampyra (dalfampridine)
Androgel (testosterone gel)
Androderm (testosterone transdermal)
Apokyn (apomorphine)
Aralast NP (alpha-1 proteinase inhibitor) - Medical Benefit Drug
Arcalyst (rilonacept) – Medical Benefit Drug
Atrigel (leuprolide) - Medical Benefit Drug
Avita (tretinoin 0.025%)
Axiron (testosterone solution)
Azelex (azelaic acid 20%)

B
Banzel (rufinamide)
Baxdela (Delafloxacin)
Benlysta (belimumab) – Medical Benefit Drug
Berinert (C1 Esterase Inhibitor) - Medical Benefit Drug - PA for Prophylaxis
Botox (Botulinum toxin)

C
Carimune NF (immune globulin) - Medical Benefit Drug
Cayston (aztreonam lysine Inhalation Solution)
Cerezyme (imiglucerase) - Medical Benefit Drug
Cimzia (Certolizumab)
Cinqair (reslizumab) - Medical Benefit Drug
Cinryze (C1 Esterase Inhibitor) - Medical Benefit Drug - PA for Prophylaxis
Compounds (>$100) 
Constipation Agents
Corlanor (ivabradine) 
Cosentyx (secukinumab) - Indication Based
Crinone

D
Dexcom Personal CGM
Differin (adapalene)
Dificid (fidaxomicin)
Dysport (Botulinum toxin)


Elelyso (taliglucerase alfa) - Medical Benefit Drug
Eligard (leuprolide)
Emsam Patch (selegilene) 
Enbrel (etanercept) - Indication Based
Endometrin
Entocort EC (budesonide) 
Entresto (sacubitril/valsartan)
Entyvio (vedolizumab) - Medical Benefit Drug
Erivedge (vismodegib)

F
Fanapt (iloperidone) /
Fasrena (Benralizumab) - Medical Benefit Drug
Finacea (azelaic acid 15%)
Firazyr (icatibant) - PA for Prophylaxis
Flebogamma (immune globulin) - Medical Benefit Drug
Forteo (teriparatide)

G
Gammagard Liquid (immune globulin) - Medical Benefit Drug
Gammagard S/D (immune globulin) - Medical Benefit Drug
Gammaplex (immune globulin) - Medical Benefit Drug
Gammar-P I.V. (immune globulin) - Medical Benefit Drug
Gamunex (immune globulin) - Medical Benefit Drug
Glassia (alpha-1 proteinase inhibitor) - Medical Benefit Drug
Glucose Test Strip Quantity Limit
Gocovri (Amantadine ER)
Grastek (grass pollen allergen)Growth Hormone - Initiation
Growth Hormone - Continuation 
Guardian Personal CGM 

H
Haegarda (C1 Esterase Inhibitor) - PA for Prophylaxis
Hepatitis C
Hereditary Angioedema
Hizentra (immune globulin) - Medical Benefit Drug
Human Chorionic Gonadotropin/Clomiphene (Novarel, Pregnyl) - Medical Benefit Drug
Humira (adalimumab)

I
Ilaris (canakinumab) – Medical Benefit Drug
Immunoglobulin (IV & SC) - Medical Benefit Drug
Inflectra (Infliximab-dyyb) - Medical Benefit Drug
Invega (paliperidone)

K
Kalbitor (ecallantide) — Medical Benefit Drug - PA for Prophylaxis
Kanuma (sebelipase alfa) - Medical Benefit Drug
Kevzara (Sarilumab)
Kineret (Anakinra)

L
Latuda (lurasidone)
Lemtrada (alemtuzumab) — Medical Benefit Drug
Letairis (ambrisentan)
Linzess (linaclotide)
Lovaza (omega-3-acids)
Lumizyme (alglucosidase alfa) - Medical Benefit Drug
Lupron (leuprolide) - Medical and Pharmacy Benefit Drug
Lyrica (pregabalin)

M
Makena - Medical Benefit Drug
Medtronic Personal CGM

Mekinist (trametinib)
Metozolv ODT (metoclopramide)
Movantik (naloxegol)
Multiple Sclerosis (interferons) - Medical and Pharmacy Benefit Drug
Myobloc (Botulinum toxin)

N
Neulasta (Pegfilgrastim) - Medical and Pharmacy Benefit Drug
Novarel (Human Chorionic Gonadotropin/Clomiphene) - Medical Benefit Drug
Noxafil (posaconazole)
Nplate (romiplostim) 
Nucala (mepolizumab) - Medical Benefit Drug

O
Ocrevus (ocrelizumab) - Medical and Pharmacy Benefit Drug

Odactra (house dust mite allergen)

Olopatadine ophthalmic
Onfi (clobazam) 
Oral and Infused Cancer Medications
Oral and Self-Injectable MS Medications
Orencia (Abatacept) - 

Opsumit (macitentan) 

Oralair (five-grass pollen allergen)
Otezla (apremilast) - Indication Based
Oxandrin (oxandrolone)

P
Potiga (ezogabine)
Pregnyl (Human Chorionic Gonadotropin/Clomiphene) - Medical Benefit Drug
Privigen (immune globulin) - Medical Benefit Drug
Primary Prevention of Breast Cancer Medication
Probuphine (Buprenorphine Implant) - Medical Benefit Drug
Prolastin C (alpha-1 proteinase inhibitor) - Medical Benefit Drug
Prolia (denosumab) – Medical Benefit Drug
Promacta (eltrombopag)

R
Radicava (Edaravone) - Medical Benefit Drug
Ragwitek (short ragweed pollen allergen extract)Regranex (becaplermin)
Relistor (methylnaltrexone)
Remicade (infliximab) - Medical Benefit Drug
Renflexis (Infliximab-abda) - Medical Benefit Drug
Renova (tretinoin 0.02%)
Repatha (evolocumab)
Restasis (cyclosporine ophthalmic)
Retin-A-Micro (tretinoin)
Ruconest (C1 Esterase Inhibitor Recomb) - Medical Benefit Drug - PA for Prophylaxis
Rytary (carbidopa/levodopa ER)

 

S
Sabril (vigabatrin)
Samsca (tolvaptan)
Savella (milnacipran) 
Simponi (Golimumab)
Soliris (Eculizumab) - Medical Benefit Drug
Spinraza (nusinersin) - Medical Benefit Drug
Stelara (ustekinumab) - Indication Based
Striant (testosterone buccal)
Supprelin LA (histrelin) - Medical Benefit Drug
Synagis (palivizumab) - Medical Benefit Drug

T
Taclonex (betamethasone dipropionate 0.064% calcipotriene 0.005%)
Tafinlar (dabrafenib) 
Taltz (Ixekizumab)
Testim (testosterone gel)
Testosterone Injections - Medical Benefit Drug 
Tikosyn (dofetilide)
Tracleer (bosentan)
Tretinoin & Vitamin A Analogues (topical)
Triptodur, Trelstar (triptorelin) - Medical Benefit Drug
Tysabri (natalizumab) - Medical Benefit Drug

Vantas Preferred (histrelin) - Medical Benefit Drug
Vfend (voriconazole)
Vimpat (lacosamide) 
Vivaglobin (immune globulin) - Medical Benefit Drug
Vivitrol (naltrexone IM) - Medical and Pharmacy Benefit Drug

X
Xadago (safinamide)
Xeljanz (tofacitinib) - Indication Based
Xenazine (tetrabenazine)
Xeomin (Botulinum toxin)
XGEVA (denosumab) - Medical Benefit Drug
Xiidra (lifitegrast ophthalmic)
Xifaxan (Rifaximin) - Pharmacy Benefit Drug
Xolair (omalizumab) - Medical Benefit Drug

Y
Yervoy (ipilimumab) - Medical Benefit Drug

Z
Zavesca (miglustat)
Zelboraf (vemurafenib)
Zemaira (alpha-1 proteinaise inhibitor) - Medical Benefit Drug
Zenpep (pancrelipase)
Zinplava (bezlotoxumab) - Medical Benefit Drug


Forms listed alphabetically by their generic name

Contact Pharmacy Services at (608) 260-7803, (800) 545-5015, or PPICInfo@QuartzBenefits.com

Members with an urgent life-threatening medication prior authorization request please contact Pharmacy Services directly at (608) 260-7803 or fax (608) 327-0324 Monday through Friday before 5 p.m. For assistance outside of regular business hours or holidays, please leave a detailed voicemail or submit a prior authorization form clearly marked "Urgent" or "Expedited."

A
Abatacept (Orencia) - Medical and Pharmacy Benefit Drug
adalimumab (Humira) - Indication Based
adapalene (Differin)
alemtuzumab (Lemtrada) - Medical Benefit Drug
alglucosidase alfa (Lumizyme) - Medical Benefit Drug
alpha-1 proteinase inhibitor - Medical Benefit Drug
Amantadine ER (Gocovri)
ambrisentan (Letairis) 
Anakinra (Kineret)
apomorphine (Apokyn)
apremilast (Otezla) - Indication Based
azelaic acid 15% (Finacea)
azelaic acid 20% (Azelex)
aztreonam lysine Inhalation Solution (Cayston)

B
becaplermin (Regranex)
belimumab (Benlysta) – Medical Benefit Drug
Benralizumab (Fasenra) - Medical Benefit Drug
betamethasone dipropionate 0.064% calcipotriene 0.005% (Taclonex)
bezlotoxumab (Zinplava) - Medical Benefit Drug
bosentan (Tracleer)
Botulinum toxin (Botox, Dysport, Myobloc, Xeomin)
budesonide (Entocort EC)
Buprenorphine Implant - Medical Benefit Drug

C
C1 Esterase Inhibitor (Berinert) - Medical Benefit Drug - PA for Prophylaxis
C1 Esterase Inhibitor (Cinryze) - Medical Benefit Drug - PA for Prophylaxis
C1 Esterase Inhibitor Recomb - Medical Benefit Drug - PA for Prophylaxis
canakinumab (Ilaris) – Medical Benefit Drug
carbidopa/levodopa ER (Rytary) 
Certolizumab (Cimzia)
clobazam (Onfi)
cyclosporine ophthalmic (Restasis) 
Compounds(>$100)
Constipation Agents

D
dabrafenib (Tafinlar)
dalfampridine (Ampyra)
Delafloxacin (Baxdela)
denosumab (Prolia) – Medical Benefit Drug
dofetilide (Tikosyn)

E
ecallantide (Kalbitor) - Medical Benefit Drug - PA for Prophylaxis
Eculizumab (Soliris)
Edaravone (Radicava) - Medical Benefit Drug
eltrombopag (Promacta) 
etanercept (Enbrel) - Indication Based
evolocumab (Repatha)
ezogabine (Potiga)

F
fidaxomicin (Dificid)

Five-grass pollen allergen (Oralair)

G
Glucose Test Strip Quantity Limit
Golimumab (Simponi)
grass pollen allergen (Grastek)Growth Hormone - Initiation
Growth Hormone - Continuation

H
Hepatitis C
histrelin - Medical Benefit Drug

house dust mite allergen (Odactra)Hydroxyprogesterone Caproate - Medical Benefit Drug
Hydroxyprogesterone Compounded - Medical Benefit Drug

I
icatibant (Firazyr) - PA for Prophylaxis
iloperidone (Fanapt) 
Imiglucerase (Cerezyme) - Medical Benefit Drug
Immunoglobulin (IV & SC) - Medical Benefit Drug
Infliximab (Remicade) - Medical Benefit Drug
Infliximab-abda (Renflexis) - Medical Benefit Drug
Infliximab-dyyb (Inflectra) - Medical Benefit Drug
Ipilimumab (Yervoy) - Medical Benefit Drug
ivabradine (Corlanor) 
Ixekizumab (Taltz)

L
lacosamide (Vimpat)
leuprolide 
lifitegrast ophthalmic (Xiidra)
linaclotide (Linzess) 
lubiprostone (Amitiza) 
lurasidone (Latuda)

M
macitentan (Opsumit) 
mepolizumab (Nucala) - Medical Benefit Drug
methylnaltrexone (Relistor)
metoclopramide (Metozolv ODT)
miglustat (Zavesca)
milnacipran (Savella)
Multiple Sclerosis (Interferons) - Medical and Pharmacy Benefit Drug

N
Naltrexone IM (Vivitrol) - Medical and Pharmacy Benefit Drug
Naloxegol (Movantik)
natalizumab (Tysabri) - Medical Benefit Drug 
nusinersin (Spinraza)

O
Ocrevus (ocrelizumab) - Medical Benefit Drug
Olopatadine ophthalmic 
ombitasvir/paritaprevir/ritonavir/dasabuvir (Viekira Pak)
omalizumab (Xolair) - Medical Benefit Drug
omega-3-acids (Lovaza)
Oral and Infused Cancer Medications
oxandrolone (Oxandrin)

P
paliperidone (Invega)
palivizumab (Synagis) - Medical Benefit Drug
pancrelipase (Zenpep)
Pegfilgrastim (Neulasta) - Medical and Pharmacy Benefit Drug
Personal > 7 Days Continuous Glucose Monitoring
posaconazole (Noxafil)
pregabalin (Lyrica) 
Primary Prevention of Breast Cancer Medication 
Progesterone in Oil - Medical Benefit Drug
Progesterone Vaginal Gel or Insert

R
ragweed pollen allergen extract (Ragwitek)repository corticotropin (Acthar Gel)
reslizumab (Cinqair) - Medical Benefit Drug
Rifaximin (Xifaxan) - Pharmacy Benefit Drug
rilonacept (Arcalyst) – Medical Benefit Drug
riociguat (Adempas)
romiplostim (Nplate)
rufinamide (Banzel)


sacubitril/valsartan (Entresto) 
safinamide (Xadago) 
Sarilumab (Kevzara)
sebelipase alfa (Kanuma) - Medical Benefit Drug
secukinumab - Indication Based
selegilene (Emsam Patch)

short ragweed pollen allergen extract (Ragwitek)

Taliglucerase alfa (Elelyso) - Medical Benefit Drug
teriparatide (Forteo)
Testosterone buccal (Striant)
Testosterone Products - Medical and Pharmacy Benefit Drug
Testosterone transdermal (Androderm)
Testosterone solution (Axiron)
tetrabenazine (Xenazine)
Tocilizumab (Actemra SC) - Indication Based
tofacitinib (Xeljanz) - Indication Based
tolvaptan (Samsca)
trametinib (Mekinist)
Tretinoin & Vitamin A Analogues (topical) 

U
ustekinumab (Stelara) - Indication Based 

V
vedolizumab (Entyvio) - Medical Benefit Drug
vemurafenib (Zelboraf)
vigabatrin (Sabril)
vismodegib (Erivedge)
voriconazole (Vfend)  

Z


Clarification on PA forms that contain more than one drug

GNRH Agonists - Medical and Pharmacy Benefit Drugs

  • Lupron (leuprolide) - Medical or Pharmacy Benefit
  • Eligard (leuprolide) - Medical or Pharmacy Benefit
  • Atrigel (leuprolide) - Medical Benefit Drug
  • Vantas (histrelin) - Preferred Medical Benefit Drug
  • Supprelin LA (histrelin) - Medical Benefit Drug
  • Triptodur, Trelstar (triptorelin) - Medical or Pharmacy Benefit

Hereditary Angioedema

  • Berinert (C1 Esterase Inhibitor) – Medical Benefit Drug
  • Cinryze (C1 Esterase Inhibitor) – Medical Benefit Drug
  • Firazyr (icatibant)
  • Haegarda (C1 Esterase Inhibitor)
  • Kalbitor (ecallantide)—Medical Benefit Drug
  • Ruconest (C1 Esterase Inhibitor)

Immunoglobulin (IV & SC) Prior Authorization Form - Medical and Pharmacy Benefit Drug

  • Bivigam, Carimune NF, Cuvitru, Flebogamma, Gamastan SD, Gammagard, Gammagard SD, Gammaked, Gammaplex, Gammar-P IV, Gamunex-C, Hizentra, Hyqvia, Octagam, Privigen, Vivaglobin and immune globulin gamma NOS

Multiple Sclerosis Interferons - Medical and Pharmacy Benefit Drug

  • Betaseron (interferon beta-1b)
  • Extavia (interferon beta-1b)
  • Rebif (interferon beta-1a)

Oral and Infused Cancer Medications Requiring Prior Authorization
(may not be a comprehensive list -- list may change at any time for any reason)

Oral and Infused Cancer Medications Prior Authorization Form - Medical or Pharmacy Benefit

  • Pharmacy Benefit Medication: Pharmacy benefit oral cancer medications which require prior authorization are listed on the Physicians Plus formulary, located at https://www.pplusic.com/providers/pharmacy/formularies. If a specific medication is not listed on the Physicians Plus formulary document, please submit a prior authorization request.
  • Medical Benefit Medications: Bavencio (avelumab), Blincyto (blinatumomab), Cyramza (ramucirab), Darzalex (daratumumab), Empliciti (elotuzumab), Imfinzi (durvalumab), Keytruda (pembrolizumab), Kyprolis (carfilzomib), Opdivo (nivolumab), Portrazza (necitumumab), Sylvant (siltuximab), Tecentriq (atezolizumab), Xofigo (Radium ra-223 dichloride), Yervoy (ipilimumab), Yondelis (trabectedin)

Progestins – Medical and Pharmacy Benefit drugs

  • Hydroxyprogesterone Caproate (Makena) Medical Benefit Drug
  • Hydroxyprogesterone Compounded Medical Benefit Drug
  • Progesterone in Oil Medical Benefit Drug
  • Progesterone Vaginal Gel (Crinone) Pharmacy Benefit
  • Progesterone Vaginal Insert (Endometrin) Pharmacy Benefit

Testosterone Replacement Prior Authorization - Medical and Pharmacy Benefit Drug

  • Preferred Products: Androderm, Androgel, testosterone cypionate, testosterone enanthate
  • Non-preferred Products: Aveed, Axiron, Delatestryl, Dep-Testosterone, Fortesta, Natesto, Striant, Testim, Testone, Testopel, Testosterone, Vogelxo

Tretinoin and Vitamin A Analogues (topical)

  • Avita (tretinoin 0.025%)
  • Azelex (azelaic acid 20%)
  • Differin (adapalene)
  • Finacea (azelaic acid 15%)
  • Renova (tretinoin 0.02%)
  • Retin-A-Micro (tretinoin)
  • Tretinoin, generic
TNF Inhibitors - Medical and Pharmacy Benefit Drugs

Other Medical Benefit Restricted Medications

Prior Authorization Required: Dysport (AbobotulinumtoxinA), Xeomin (IncobotulinumtoxinA), Botox (OnabotulinumtoxinA), Myobloc (RimabotulinumtoxinB), Actemra (tocilizumab), Dupixant (dupilumab), Hemlibra (emcizumab), Myozyme (alglucosidase alfa), Radicava (edaravone), Siliq (brodalumab), Simponi Aria (golimumab), Stelara (ustekinumab), Orencia (abatacept)
 
Age Restricted Vaccines:
  • Human papillomavirus vaccine (Cervarix, Gardasil, Gardasil-0) - Prior authorization required for ages < 9 years OR > 26 years
  • Varicella-zoster vaccine (Shingrix) - Prior authorization required for age < 50 years
  • Varicella-zoster vaccine (Zostavax) - Prior authorization required for age < 60 years
Excluded Medications (Not Covered):
  • Brineura (cerliponase) and Exondys 51 (eteplirsen)
Miscellaneous Codes (examples; J3490, J3590):
  • Prior authorization required for billed amount > $2500