Using Your Pharmacy Benefits


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Important Questions to Ask

How often does Unity’s Prescription Drug Formulary change?
The Pharmacy and Theraputics (P&T) Committee meets monthly to review Unity’s Prescription Drug Formulary. Most changes to the formulary involve the addition of new drugs or drugs which are newly available as generics. On occasion, drugs are removed from the formulary or moved to restricted status. Unity’s Prescription Drug Formulary is updated monthly, so be sure to check the web site or request an updated version from Unity Customer Service. Be sure to read your copy of UnityNews for more information about additions and changes to Unity’s Prescription Drug Formulary.

What happens when a drug I’m taking changes its formulary status?
If the drug you are taking changes from formulary to non-formulary, you can continue to receive coverage for the drug at the Tier 3 copay. If you have had a recent claim for the medication as a Unity member, you and your practitioner will receive a detailed notification of the formulary change and your options BEFORE the change occurs. You will be given sufficient time to discuss your options with your practitioner and make a decision. You generally have two options:

  1. Continue taking the drug at the Tier 3 copay level
  2. Switch to an appropriate formulary version of the medication to receive coverage at the formulary copay level

What happens when a drug I am taking is changed to restricted status?
If you are taking a drug that becomes a restricted drug, your coverage may change in one of two ways depending on the properties of the medication and the diseases it treats:

  1. If the P&T Committee decides it is not safe for the patient to stop taking the medication, or is difficult to transition patients off the newly restricted drug, they will allow you to continue to have coverage for the drug without having to obtain Prior Authorization. Only patients newly beginning the drug after it becomes restricted need Prior Authorization to receive coverage.
  2. If the P&T Committee decides it is safe and appropriate to transition patients to a new medication, you will need an approved Prior Authorization for continued coverage of the medication that became restricted. At any copay level, if you have had claims with Unity for a medication that is newly restricted, you and your practitioner will receive a detailed notification of the change and your options BEFORE the change occurs. You will be given sufficient time to discuss your options with your practitioner before you need to make a decision. You generally have three options in this situation:
  • Switch to an appropriate formulary medication that does not require Prior Authorization to receive coverage at the formulary copay level
  • Ask your practitioner to request Prior Authorization for continued coverage of the medication
  • Continue taking the drug without coverage through your Unity benefit (you pay the full cost)

Your notification before the change will include details on the specific medications that are available.

If my Prior Authorization Request is denied, is there a way to appeal that decision?
If you disagree with Unity’s decision to deny coverage for a drug, you have a right to appeal the decision. You can appeal a denial of coverage by contacting Unity Customer Service at 800-362-3310. Your appeal will be reviewed by a panel of experts who will consider whether the decision should be changed based on your medical condition and your specific Unity benefits.

What can I do to ensure that the prescriptions my practitioner gives me are for formulary medications at the lowest possible copay?
The best way to ensure that the prescriptions you receive are for covered formulary medications is to tell your practitioner that you are a Unity member before the prescriptions are written. Let your practitioner know that you would like formulary and/or generic medications if appropriate for treating your medical condition. If your practitioner provides you with drug samples to start treatment, find out if the medication is on Unity’s Prescription Drug Formulary. Starting with samples does not guarantee that the medication will be covered or covered at the lowest possible copay.

Why does my coverage only pay for a one-month supply of medication at a time?
Your Unity Prescription Drug Benefit provides coverage for a one-month supply of most medications for a couple of reasons. First, providing coverage for one month of medications reduces waste that occurs when a medication is switched, or the dosage is increased. Even chronic medications that you have been taking for some time may unexpectedly change and the remaining quantity of that medication is then thrown away.
Second, allowing coverage of a greater supply of medications allows members whose coverage with Unity will be terminating to stockpile a supply of medications just before their membership ends. This stockpiling increases the cost of medications and impacts your premiums as a continuing member.

How can I obtain reimbursement for medications I had to purchase out-of-pocket?
You’ll need to complete and submit a Direct Member Reimbursement Prescription Claim Form (DMR). The DMR is used to reimburse members for covered prescription drugs that were filled at a non-participating pharmacy due to an emergency or other unforeseen circumstances. For example, let’s assume you’re on vacation and develop a sinus infection. You receive a prescription and have it filled at the local pharmacy where you are vacationing. Because the local pharmacy is not a Unity-participating pharmacy, you have to pay the full cost of the medication at the pharmacy. When you return from vacation, you should complete the DMR to receive reimbursement. To be reimbursed, follow these steps:

  1. Print a copy of the form (available on Unity’s web site at unityhealth.com or by calling 800-362-3310)
  2. Complete the form—be sure to follow the directions carefully
  3. Attach all receipts for the prescription medications noted on the form 
  4. Mail form and attached receipts to the address indicated on the form

You will receive reimbursement roughly 4 weeks after the request is received. The amount paid will be less your copay. DMR forms received more than 18 months from the date the prescription was filled are not eligible for reimbursement. Reimbursement is not guaranteed. If you have any questions regarding this form or the status of your reimbursement, please call Unity Pharmacy Services at 800-788-2949.

How is the determination made whether a drug is classified as generic or brand?
There are many ways to classify drugs as either brand or generic. The most common process is to call the first version of that medication to be available on the market “the brand” (for example, Prozac). When the patent expires for the brand, other manufacturers may market versions of the medication; these versions are considered “generics” (for example, fluoxetine is the generic of Prozac, and fluoxetine is marketed by several companies). Because determining brand/generic status is not always this straightforward, brand/generic status for your drug benefit with Unity is determined using a national database of medication-related information called the First Data Bank National Drug Data File. The brand or generic status of a medication as listed in First Data Bank determines whether that medication is considered a generic or a brand on Unity’s Prescription Drug Formulary.