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 ‚Äčan 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
08/20/2019





You must click on all files you wish to upload using CTRL and then click Upload
Member Information


Pharmacy Information and Medication Information
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.**