Provider Prior Authorization Resources

Medication Prior Authorization

Drug prior authorization and exception requests

Medication PA Forms + Info

Medication PA List

Medication PA Criteria

General Prior Authorization

General PA List

General PA List – Illinois

General PA List – Quartz PPO (Cigna PPO Network*)

General PA List – Quartz PPO (PHCS/MultiPlan/HealthEOS PPO)

General PA Request Form

Fulcrum Out-of-Network Chiropractic Prior Authorization Form

Medicare Advantage Prior Authorization

Medicare Advantage PA List

Quartz Align Prior Authorization

Trane Members

GLAS Members

Southwest Health Members

ePA Makes Prior Authorization Easier

The ePA program enables providers to initiate prior authorizations in the patient’s electronic medical record. For more information, visit Optum’s website.

Behavioral Health Prior Authorization

Initial mental health request forms:

Initial Mental Health Treatment Request Form

AODA Initial Request Form

Do not use these forms to request prior authorization (PA) for TMS. 

A PA is only required for outpatients if the request is for services with an out-of-network provider.

Extension request forms:

Mental Health Treatment Extension Request Form

AODA Extension Request Form

Use these forms to request an extension of a previously approved request.

Transcranial Magnetic Stimulation Request Form

This form is used without the Initial Mental Health Treatment Request. 

Eating Disorder Supplemental Request Form

This form is used in addition to the Initial Mental Health Treatment Request or the Mental Health Treatment Extension Request forms.

Prior Authorization Data

• Individual and Groups – Illinois
• Illinois 2021 Prior Authorization
• Minnesota 2021 Prior Authorization
• Individual and Groups – Minnesota

*The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration. Cigna is an independent company and not affiliated with Quartz. Access to the Cigna PPO Network is available through Cigna’s contractual relationship with Quartz. All Cigna products are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.