This program allows you to buy a 90-day supply of certain medications. If you are interested, read more.
Medicines only work properly if they are taken as directed by your doctor. This is called adherence. Patients that adhere to their treatment plans tend to stay healthier, use fewer health services and have a better quality of life.
Your employer may have included Value Tier pricing in your coverage. If so, you can get certain high-value drugs at a lower copay. This is called Value Tier pricing.
To take advantage of this, check your Schedule of Benefits to see if your plan includes “Rx Outcomes.” If it does, check the formulary and see Appendix B.
This great benefit gives members lower cost access to the drugs that improve medical results the most.
Unity’s Specialty Pharmaceutical Program provides high-quality clinical monitoring for patients using specialty medications while keeping coverage of these products affordable. This helps make sure patients get the best possible results from these complicated and expensive medications. Specialty medications must have prior authorization and must be provided by a pharmacy in the Specialty Pharmaceutical Program (UW Health Pharmacies.) Members will not be charged for shipping by standard mail. The medicine may also be picked up at the pharmacy.
Members new to Unity may be taking medicines that need a Prior Authorization for coverage. Unity’s formulary will note the drugs that need Prior Authorization. In this case, Unity will authorize coverage for these drugs for up to 90 days (in 30 day increments at the usual copayment). After those 90 days, prior authorization will be required for additional coverage. In the meantime, new members should talk to the doctor who prescribed the medicine. The doctor can check to see if a different drug will work.
To request a “New Member Override,” you or your pharmacy can call Unity Pharmacy Services at 800.788.2949. This should be done within the first 90 days of becoming a Unity member.
Please note: this policy only applies to medications that a member was taking prior to joining Unity. Standard copays based on the member’s drug benefit and formulary status of the medication apply.
Medications that were covered by your previous insurance prescription drug benefit do qualify for a New Member Drug Supply.
Medications that do not qualify for a New Member Drug Supply include –
- Medications that were not covered by your prior insurance drug benefit
- Medications provided by Sponsored Free Drug Programs from drug companies.
At times, you may have an urgent need for medicine that requires Prior Authorization. If you don’t have time to wait for Prior Authorization approval, talk to your pharmacist. Your pharmacy can call Unity Pharmacy Services at 800.788.2949 to get coverage for a five-day emergency supply. During the five days, it is your responsibility to talk to your doctor. Ask your doctor for a similar medicine or ask the doctor to submit a Medication Prior Authorization Request Form to ensure continued coverage.
The emergency supply policy does not apply to all medications. It does not include drugs that –
- Are excluded from coverage on your Unity Prescription Drug Benefit
- You have had previous emergency coverage
No copay is charged for the emergency supply. A full copay is charged for any additional orders of the medication.
Members who are planning to travel should make sure they have enough medication for their entire trip. Do this one of three ways –
- Call Unity Pharmacy Services at 800.788.2949 to get approval for an extra 30-day supply to take with you (copays apply).
- You can have your pharmacy send your medicine to your vacation address.
- Or, you can go to a Unity-participating pharmacy where you’re staying. Unity has a national network of participating pharmacies from which you can receive medications. These pharmacies include CVS, KMart, Kroger, Longs, Medicine Shoppe, Osco, Publix, Rite Aid, SafeMart, Shopko, Target, Walgreens, Walmart and more. Use Unity’s Find a Pharmacy tool or contact Unity Pharmacy Services for help identifying participating pharmacies in the area where you’re traveling. To pick up your prescription at one of these pharmacies, you need to call ahead give them the name and phone number of the pharmacy where you last filled the prescription. They will call and transfer the remaining refills.
At times, you may need to pay the full cost of a prescription when traveling. In this case, you can fill out a Direct Member Reimbursement Form and include proof of payment. Unity will pay you back based on your plan coverage.
Members traveling outside of the United States may be covered for up to an additional 90-day travel supply of medications.
To access this addition to their benefit, members need to –
- Maintain their Unity membership for the entire period of travel
- Fully complete the International Extended Travel Pharmacy Supplies Form by downloading, printing and faxing or submitting the online form via SECURE electronic transmission
- Submit the form with travel verification documents to the Quartz Pharmacy Program at least 30 days prior to departure
If approved, members will pay one copay or other applicable cost share based on their benefits for each 30-day supply of medication authorized. The quantity of medication authorized may vary based on recent member claims, Unity coverage term dates and travel information submitted.
If medication supplies greater than the amount authorized are needed, the additional supply will need to be purchased at full cost. This cost may be eligible for Direct Member Reimbursement upon return from travel. This is only available if members maintain continuous Unity prescription coverage throughout the trip and through the completion of the reimbursement process.
Sometimes there are a lot of different drugs that treat the same illness. Some may cost very little and others may be very expensive, but may work just as well. That’s why Unity has the Step Therapy Program. This means that members must try the most cost-effective medications before stepping up to an expensive drug. Many members find the first medication very effective and never need to step up.
Step therapy medications need Prior Authorization for coverage. Every Prior Authorization Request for step therapy drugs is reviewed separately. Each drug has specific criteria for approval. Preferred or non-preferred drugs may be included in a step therapy program. Go to the Unity formulary to see which drugs have a "ST". These require Prior Authorization.
The purpose of this policy is to ensure you receive an effective drug at the lowest cost.
A generic drug contains the same active ingredient (the specific chemical ingredient that makes a drug work) as the brand drug. It must have the same dosing and labeling as the brand drug, and must meet the same standards for purity and quality. The FDA must approve generic drugs as equivalent to the brand before allowing them to be marketed as interchangeable. Because the FDA has determined the generic to be equivalent, your pharmacist can dispense the generic version of your medication without a new prescription from your physician.
Unity’s Generic Substitution Policy states that when FDA approved equivalent generics are available, coverage of the brand product is only provided with an approved Prior Authorization.
Generic Substitution Policy Exception Prior Authorization Request Form
Quartz Health Solutions is committed to reducing the inappropriate use of prescription opioids. Excessive use of opioids can lead to addiction, overdose, and death.
New restrictions will be in place effective 8/1/2018 for Quartz (fully-insured) commercial members. These restrictions will limit:
- The number of days’ supply that can be filled for opioid naïve members (7 days or less)
- The dose of opioids members can receive (cumulative daily dose of 120 morphine milligram equivalents (MME) will require an approved Prior Authorization (PA)* ‡
- The use of opioids in combination with other medications that may be inappropriate
* In order to avoid interruptions in therapy, members who are currently using opioids at a dose >120 MME can continue filling their opioids until 12/1/2018. This provides current utilizers time to obtain a prior authorization to continue therapy. Current members who are identified as needing to complete a Prior Authorization will be notified of this new requirement.
‡ Prior Authorization criteria is as follows:
ONE of the following conditions applies: cancer-related pain, hospice, palliative, end-of-life, or long term care (LTC) residence.
ALL of the following apply:
- Prescriber statement indicating the dose being prescribed is medically necessary AND
- The PDMP has been checked in the past month AND
- Pain contract is in place AND
- Prescription for naloxone (example: Narcan nasal spray) sent to the pharmacy AND
- Urine compliance screen in previous 12 months