Understanding your Patients' Coverage


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Understanding Patient Coverage

To meet the wide-ranging needs of the marketplace, Unity offers a variety of pharmacy benefits. Understanding a few basics about each type of pharmacy benefit will help you answer some of the questions your patients may have.

Unity currently sells 3 primary types of pharmacy benefit:

1. Three-Tier Benefit - The majority of Unity’s members with a drug plan have a Three-Tier Benefit. With this benefit, Formulary medications are covered at 1st tier (Formulary-Generic) or 2nd tier (Formulary-Brand Name) copayment levels. Most Non-Formulary medications do not require prior authorization for coverage. Instead, they are covered at a higher (3rd tier) copayment level. Copayment amounts for each tier will vary, depending on the plan the employer purchases. Certain restricted medications (Formulary or Non-Formulary) still require prior authorization for coverage, but the need for prior authorization is significantly reduced compared to the Closed Formulary Benefit.

Please note: Unity will not authorize a 3rd tier copayment drug as a 2nd tier copayment drug. Copayment tiers are fixed based on Formulary status. Brand Name/Generic status will not be adjusted based on individual circumstances.

2. Closed Formulary Benefit - With a Closed Formulary Benefit, ALL Non-Formulary medications require an approved prior authorization for coverage. For Formulary and approved Non-Formulary medications, there may be one (same copayment for Brand Name and Generic) or two (1st tier for Generic, 2nd tier for Brand Name) copayment tiers. Copayment amounts for each tier will vary, depending on the plan the employer purchases.

3.Health Savings Account High Deductible Benefit - Unity offers a new type of drug benefit for High Deductible Health Plans offered in conjunction with Health Savings Accounts (HSAs). With this benefit, the member pays 100% of the cost of prescriptions and medical care until an annual deductible (combining pharmacy and medical costs) is met. Once the deductible is met, the member pays nothing for covered prescriptions until the end of the benefit year. Currently, deductible amounts are $1,100 for individuals and $2,200 for families; these amounts are indexed and may change annually. Just as with the Closed Formulary Benefit, the HSA Benefit requires an approved prior authorization for coverage of ALL Non-Formulary medications. It is important for the pharmacist to submit all claims online even though the member pays 100% of the cost until the deductible has been met. This ensures that the member receives the benefit of a lower negotiated price and that the amount paid will be applied to the deductible.

Important note: This information is not applicable to members covered under the State of Wisconsin health insurance program or the BadgerCare Plus program.  State of Wisconsin members should contact Navitus Solutions and BadgerCare Plus members should call the State Medicaid Program.