Unity Pharmacy

Medication Prior Authorization Request Form

  • Please complete the form entirely to ensure a prompt review
  • For most expedient review: Forms should be completed by healthcare provider and submitted online via SECURE electronic submission or via fax
  • Prior authorization criteria available: unityhealth.com/medicationpriorauth
  • Direct questions about medication prior authorization criteria to ​the Quartz Pharmacy Program at 888.450.4884 or 608.265.7397
  • To check the status of a PA request contact MedImpact Customer Service at 800.788.2949
  • To appeal decisions contact Unity Customer Service at 800.362.3310
Medication Prior Authorization Request Form


Step 1: Patient and Prescriber Information.

6/23/2018






















Step 2: Diagnosis and Medication Information.
















Step 3: For Clinic / Physician Administered Medications Only.











* - Required Field
**Prescribers will be notified by fax and members will be notified by mail when a decision has been determined.**