International Extended Travel Medication Supply Form

PLEASE FOLLOW THE INSTRUCTIONS VERY CAREFULLY
Submit your documents at least 30 days prior to departure.
  • Please complete the form entirely to ensure a prompt review - incomplete forms will be denied
  • Forms should be completed by the member and submitted via fax or online
  • Travel verification documents (travel agency itinerary, copy of plane tickets, etc.) must be included
  • Members will receive one (1) phone call informing them we have received their request
  • Members will receive ​an approval or denial letter in the mail
  • An approved request is required prior to travel
  • Direct questions about the form can be directed to 888.450.4884 or 608.265.7397
If the request is approved, coverage will include:
  • Current 30 day supply of medication
  • A maximum medication supply of 120 days on hand (The quantity of medication authorized may vary based on recent member claims, Quartz coverage term dates, and travel information submitted.)
  • Member will be responsible for their usual cost sharing (copays, coinsurance) per 30 day supply authorized
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.
PRINT AND FAX FORM
PLEASE NOTE: LIMIT OF FIVE (5) DOCUMENTS FOR UPLOAD ON FORM BELOW
Travel Information
Departure Date is Required.
Departure date must be before return date.
Return Date is Required.

You must click on all files you wish to upload using CTRL and then click Upload
You must select at least one file.
Member Information
Member Number is Required.
Member Birth Date is Required.
First Name is Required.
Last Name is Required.
Address is Required.
City is Required.
State is Required.
Zip Code is Required.
Format: XXX-XXX-XXXX
Phone is Required.
Pharmacy Information and Medication Information
Pharmacy Name is Required.
Format: XXX-XXX-XXXX
Pharmacy Phone is Required.
Medication Name Strength Dose Days Supply  

*Indicates a required field

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