International Extended Travel Medication Supply Form
Submit your documents at least 30 days prior to departure.
If the request is approved, coverage will include:
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.
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Quartz Health Solutions, Inc., Unity Health Plans Insurance Corporation, Gundersen Health Plan, Inc., Gundersen Health Plan Minnesota, Physicians Plus Insurance Corporation, Gundersen Health System, UnityPoint Health and UW Health are separate legal entities. Plans are underwritten by Unity Health Plans Insurance Corporation unless otherwise noted.