Unity’s Medication Prior Authorization Process
Certain medications require prior authorization before coverage is provided
- All medications with Prior Authorization/Restricted Status require authorization for coverage.
- Restricted medications may be Formulary or Non-Formulary. The formulary status will determine the copayment if the prior authorization request is approved. View the Medication Prior Authorization Criteria List.
- All Non-Formulary medications require prior authorization for coverage under a 2 tier (Closed Formulary) drug benefit or a drug benefit associated with a Health Savings Account.
The criteria for coverage of restricted medications are summarized in ePocrates and are listed below. If you have questions about the criteria, please contact Unity’s Pharmacy Program at 888-450-4884.
Requesting Prior Authorization for Medications
- To request coverage of a medication requiring prior authorization, complete the one-page Medication Prior Authorization Request form and fax to the number that appears on the form.
- The following clinical information is needed for each request:
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- Name of drug (and J code or CPT code, if applicable) for which coverage is requested
- Diagnosis
- Names of Formulary medications that have been tried and trial dates
- Problems with formulary medications, such as lack of effectiveness, adverse effects
- Rationale for using the Non-Formulary or restricted medication
- A clinical pharmacist will review the request, using Unity’s prior authorization criteria, and make a coverage determination.
- Requestors and patients will be notified of the decision by fax and mail, respectively.
- If the name of the pharmacy that the patient uses is included on the request, we will notify the pharmacy of the decision as well.
- Practitioners and patients may appeal a determination by calling Unity Customer Service at 800-362-3310 and notifying the representative that you wish to appeal.
- If you have questions about Unity’s prior authorization criteria or a specific determination, contact Unity’s Pharmacy Program at 888-450-4884.
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