Unity Pharmacy
Medication Prior Authorization

Certain medications require prior authorization before coverage is provided

  • All medications with Prior Authorization / Restricted Status require Prior Authorization for coverage
  • Restricted medications may be Preferred or Non-preferred. The formulary status will determine the copayment if the prior authorization request is approved
  • Many drug benefits associated with Unity’s High Deductible Health Plans (HDHPs) require prior authorization for non-preferred medications
  • If a request is Urgent, there is a 5 day emergency supply option available as well as a new member drug supply option available.
  • For urgent requests, complete the "Print and Fax" form and fax it directly to the number on the form. The request must provide clinical documentation FROM THE PRESCRIBER with the PRESCRIBER'S SIGNATURE stating why the request is urgent. Requests will only be treated as urgent for clinical reasons. Without documentation to support the urgency of the request, it may be treated as a standard request (this cannot be done using the online form).
  • Certain medications administered in a clinic require an approved medical prior authorization before administration would be covered under the medical benefit​

The criteria for coverage of restricted medications are listed below. If you have questions about the criteria, please contact the Quartz Pharmacy Program at 888.450.4884.

Please click the link below to open a PDF document of Unity’s medication prior authorization criteria for coverage. Use “control-F” to open a search box in the document and type the drug name you are looking for. Press “enter” to scroll through the document as drugs may be listed more than once.


Requesting Prior Authorization for Medications

To Request coverage of a medication requiring prior authorization, complete the Medication Prior Authorization Request form and submit online or fax to the number that appears on the form.  Requests can also be initiated via telephone but for most expedient review, forms should be completed by prescribers and submitted via SECURE electronic submission or via fax.

For requests for brand drugs when a generic form is available, please complete the Generic Substitution Exception form in full.

If you have questions about Unity’s prior authorization criteria or a specific determination, contact Unity’s Pharmacy Program at 888.450.4884.