Unison Health Plan is pleased to provide this formulary to be used when prescribing for patients covered by the pharmacy benefit plan of Unison Health Plan. This is a restricted formulary and only those drugs listed in this formulary will be covered by Unison Health Plan. The drugs listed in this formulary are intended to provide sufficient options to treat patients who require treatment with a drug from that pharmacologic or therapeutic class. The drugs listed in the Unison Health Plan  formulary have been reviewed and approved by the Unison Health Plan and Therapeutics Committee. The drugs have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through Unison Health Plan. It is also recognized there may be occasions where an unlisted drug is desired for proper medical management of a specific patient. In those infrequent instances, the unlisted medication may be requested through the Medical Exception process.

Please click below to be directed to our pharmacy formulary.

• Unison Formulary

Formulary Updates

• Pharmacy Network Plan Payer Sheet - Prescription Solutions
• Pennsylvania Formulary Updates
• Synagis Provider Bulletin

Prior Authorization and Medical Exception Forms

• Medical Exception Request Form
• CMS Coverage Determination Form
• Prior Authorization Request Form for TZDs and Combo Products
• Prior Authorization Request Form for DDAVP (desmopressin)
• Prior Authorization Request Form for Growth Hormones
• Prior Authorization Request Form for Pain Management
• Prior Authorization Request Form and Prescription Order Form for Hepatitis C Therapy
• Medical Exception Request Form and Prescription Order Form for Injectable Medications
• Prior Authorization Request Form for Suboxone/Subutex
• Medical Exception Request Form for Synagis
• Prior Authorization Request Order Form for 17-alpha hydroxyprogesterone
• Prior Authorization Request Form for PPI
• Prior Authorization Form for COX-2

Important Step Therapy Information

• Unison's Automated Prerequisite Step Therapy Policies
• Step Therapy Criteria for Advair (Fluticasone/Salmeterol)
• Step Therapy Criteria for Angiotensin Receptor Blockers (ARB)
• Step Therapy Criteria for Leukotriene Receptor Antagonists (LTRA)

Quality Initiatives

• Unison's Quality Management Drug Program
• Quantity Limits: Opiate-Containing Agents
• Quantity Limits: Migraine Analgesia, Benzodiazepines &  Muscle Relaxants

Pill Splitting

• Unison's Tablet Splitting Initiative
• Bid Dosing Redemption Sheet
• Current Pill Splitting List

Additional Pharmacy Services Program Information

• Unison's Pharmacy Program Mission
• Unison's Pharmacy Program Contact Information