Health Care Practitioners
Prior Authorization List

Monthly updates will be added to the Prior Authorization list. Providers are reminded to review the Prior Authorization list on a regular basis for any updates or changes which may be added. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Prior Authorization is the process by which the UW Health Medical Management staff or UW Health Pharmacy Benefit Management Program staff provide a written statement that the requested service or supply is medically necessary and appropriate. Prior Authorization may list the specific service or supply that is authorized, the number of visits that are authorized and the name of the provider or supplier. However, Prior Authorization does not guarantee that the service will be covered. Coverage is determined by the terms of your benefit plan. If you have questions regarding coverage, please call Unity Health Insurance at (800) 362-3310.


As an insured under Unity’s PPO Plan, you are responsible for obtaining Prior Authorization in order to receive coverage for certain services. Before you receive a service that requires Prior Authorization, you must arrange for Prior Authorization from the UW Health’s Medical Management Department. Please contact your physician to initiate the prior authorization using Unity’s Prior Authorization Request form. To verify that Unity has approved the request for Prior Authorization before you receive the service, please login to MyChart at unitymychart.com to review your Authorizations or contact Unity Customer Service at (800) 362-3310.

Durable Medical Equipment in excess of $500 in billed charges


Genetic Testing


Home Health Care Services


Home IV Therapy


Hospice Care


Inpatient Admissions

You must contact Medical Management at least 48 hours before all elective (non-emergent) hospital admissions, skilled nursing facility admissions and inpatient rehabilitation.

  • Hospitals, acute inpatient care
  • Inpatient rehabilitation facilities
  • Long term acute care
  • Psychiatric admissions
  • Skilled nursing facility / swing bed

Other Services

  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Residential treatment

Pharmacy / Medications

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via MyPlanTools or fax a Medication Prior Authorization Request Form to Quartz at (888) 450-4711.
  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Buprenorphine (Probuphine) implant
  • Cankinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Daratumumab (Darzalex)
  • Denosumab (Prolia, Xgeva)
  • Eculizumab (Soliris)
  • Elotuzumab (Empliciti)
  • Eteplirsen (Exondys) not covered – experimental
  • Golimumab IV (Simponi)
  • GNRH agonist ( leuprolide, Lupron, Vantas, Supprelin LA) for use in gender dysphoria
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine for ages outside of 9-26 years (Gardasil)
  • Hydroxyprogesterone caproate (Makena)
  • Incobotulinum (Xeomin)
  • Infliximab (Remicade, Inflectra)
  • Mepolizumab (Nucala)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palivizumab (Synagis)
  • Pegfilgrastim (Neulasta)
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Testosterone Implant (Testopel)
  • Tocilizumab (Actemra)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Xofigo (Radium 223 Dichloride)
  • Zinplava (Bezlotoxumab)
  • Zoster vaccine for age < 60 years (Zostavax)
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $500

Transplants


If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within MyPlanTools for providers or MyChart for members or call (800) 362-3310.