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Pharmacy Forms

Prescription Drug Prior Authorization or Step Therapy Exception Request Form

Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members.

Synagis Statement of Medical Necessity

Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.

Prior Authorization Information Request for Injectable Drugs

Use this form for chemotherapy, HCPCS J-code requests and other IV medication requests administered by the physician/hospital.

Treatment Authorization Request (TAR)

Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.

Medical Nutrition Therapy Benefit Quick Reference Guide

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