The criteria for coverage of restricted medications are listed below. If you have questions about the criteria, please contact UW Health Pharmacy Benefit Management 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 online 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.
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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.