The Alliance subcontracts with MedImpact to provide pharmacy services for Alliance members. Members must go to a MedImpact-participating pharmacy for prescriptions. For more information regarding the Alliance Pharmaceutical Services Access, please see Policy 403-1126 – Pharmaceutical Services Access.
The Alliance has its own drug formulary, developed under the direction of the Alliance Pharmacy & Therapeutics (P&T) Committee with input from local providers. Our formulary, which is not the same as the state formulary, is reviewed and updated quarterly by the P&T Committee and Alliance staff. Please note that since benefits vary by line of business, some drugs or classes of drugs are not covered for some members. Please refer to the Alliance Formulary to find out if a specific medication can be prescribed.
Prior authorization is necessary for a prescription drug that is not in the Alliance Drug Formulary or exceeds the limit of days, age, quantity or cost allowed per formulary. Beginning April 1, 2021, prior authorization requests for all Alliance members must be submitted by completing the Prescription Drug Prior Authorization or Step Therapy Exception Request Form. Submissions on other forms will not be accepted. In some cases, we ask that you include forms specific to a therapeutic class or drug with the prior authorization request. See the Authorizations for Physician-Administered Drugs: Prior Authorization Forms and Checklists section below for more information.
Prior Authorization Criteria:
The Alliance’s Prior Authorization Criteria outlines the general criteria by which non-formulary drugs can be prescribed. Exceptions to these criteria are made on a case-by-case basis through the prior authorization process. The Alliance prior authorization criteria is developed by our P&T Committee and is reviewed at least annually.
Submitting a prior authorization:
- Preferred method is via the Alliance Provider Portal.
- If you don’t have a Portal account, you can request an account or contact the Provider Services Portal Support Specialist at 831-430-5518. Once the Prior Authorization form is complete, either submit:
- By fax to 831-430-5851.
- By mail:
Central California Alliance for Health
Health Services Department – Pharmacy
PO Box 660012
Scotts Valley, CA 95067-0012
If you have questions about urgent prior authorization requests, please call the Alliance Pharmacy Department at 831-430-5507 or 800-700-3874, ext. 5507. Business hours are Monday-Friday, 8 a.m. to 5 p.m., excluding holidays.
To complete a prior authorization request, all of the following information must be provided:
- Member name, ID number and DOB.
- Requesting provider name and contact information.
- Description of requested drug or item. You must include Healthcare Common Procedure Coding System (HCPCS) code if a physician or facility administered drug is requested.
- Prescriber name, address, phone number and fax number.
- Pharmacy name, address, phone number and fax number (if authorization is submitted by a pharmacy).
- Diagnosis (or ICD code) that most accurately describes the indication for the medication. Please include all medically relevant diagnoses for review purposes.
- Quantity requested per fill or per date of service (DOS).
- Number of fills or DOS requested.
- Directions for use.
- Expected duration of therapy.
- Documentation of appropriate clinical information that supports the medical necessity of the requested drug or item, including:
- Other drugs or therapies for this indication that have already been tried and failed. Please include what the outcomes were.
- Why alternatives on the Alliance Formulary cannot be used.
- Any additional information to support diagnosis and medical justification such as lab results and specialist consults.
Incomplete and/or illegible forms may be denied or voided.
The Alliance prefers the use of a biosimilar if the member has not tried its branded counterpart. For more information, please see Policy 403-1142 – Biosimilars.
For providers who wish to administer Synagis in their office, the Statement of Medical Necessity form is required to be submitted along with the prior authorization request. The Alliance will cover Synagis for members who meet Conditions of Usage listed in Policy 403-1120 – Synagis.
Providers can contact the Alliance Pharmacy Department at 800-700-3874, ext. 5507.
For more information on the authorization review process, please see Policy 403-1103 – Pharmacy Authorization Request Review Process.
Physician-administered drugs that require prior authorization will have criteria consistent with pharmacy benefit criteria. This is based on the recommendations of the Pharmacy and Therapeutics Committee. Prior authorization for the pharmacy benefit will be applicable to pharmaceutical physician-administered drugs. If a physician or facility-administered drug requiring prior authorization has no prior authorization criteria, it will be reviewed for medical necessity.
For Medi-Cal members, the Alliance does not cover drugs in the following classes:
- Blood factors.
- Coagulation factors.
- Other drugs for bleeding disorders.
These carved-out drugs should be billed to state Fee-for-Service Medi-Cal. For more information on Fee-For-Service reimbursement, see the Billing and Reimbursement section of this page.
For more information on the authorization review process for physician/facility-administered drugs, please see Policy 403-1141 – Physician/Facility-Administered Drugs Requiring Prior Authorization.
Prior Authorization Forms and Checklists
In the following cases, include forms specific to a therapeutic class or drug with the Prescription Drug Prior Authorization or Step Therapy Exception Request Form or portal submission. Submitting this additional information makes the review process quicker and more efficient.
- Hepatitis C virus (HCV) Checklist: Use this resource for HCV medication requests.
- Prior Authorization Information Request for Injectable Drugs: Use this form for chemotherapy, HCPCS J-code requests and other IV medication request administered by the physician/hospital.
- High Dose Opioid Regimen Checklist: Use this form for opioid drugs that exceed our quantity limits.
- Anti-Obesity Agents Form: Submit this form for any non-formulary anti-obesity agent medication.
- Synagis Statement of Medical Necessity: Use this if Synagis is to be administered in the hospital/provider office. The Alliance will cover Synagis for members who meet Conditions of Usage listed in the Synagis Policy 403-1120 – Synagis, available in Section 16 of the Alliance Provider Manual.
- Tobacco Treatment Checklist: Use this form to communicate the need for regimen continuation.
The Alliance has developed policies in collaboration with internal and external stakeholders to help ensure the safe and appropriate use of opioid medications.
Twenty-four-hour access is provided by any 24-hour pharmacy that contracts with the Alliance’s pharmacy benefit manger (PBM). Currently, access to 24-hour pharmacies is available in Santa Cruz County (Watsonville) and Monterey County (Salinas and Seaside).
When there is an emergency after the Alliance’s business hours (Monday through Friday, 8 a.m. to 5 p.m. PST) or on holidays, the Alliance’s PBM is authorized to enter a five-day override if the pharmacy states that it is for an emergency. The Alliance will receive and retrospectively review a report of all emergency overrides placed by Alliance’s PBM, MedImpact. To contact MedImpact, call 800-788-2949.
Alternatively, pharmacies can dispense a 72-hour supply of medically necessary non-formulary medication(s) if the pharmacist deems it is an emergency and the Alliance is closed. A retroactive prior authorization request can be submitted by the pharmacy for the 72-hour supply and will be approved by the Alliance on the next business day.
In the event that a new member is being treated with a non-formulary drug at the time of their enrollment with the plan, the Alliance will work with Alliance providers to ensure that they receive continuity of care with their pharmaceutical services.
For more information on continuity of care for new members, please see Policy 403-1114 – Continuing Pharmacy Care for New Members.
The Alliance operates a DUR program to educate physicians and pharmacists to better identify patterns and reduce the frequency of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care. The program applies to physicians, pharmacists and patients, and to fraud or abuse associated with specific drugs or groups of drugs. For more information on the DUR program, please see Policy 403-1143 – Drug Utilization Review. For DUR program related to opioids, see Policy 403-1139 – Opioid Utilization Review. For Medi-Cal DUR Educational Articles by DHCS, see below.
- Drug Safety Communication: Potential Increased Arrhythmia Risk from Lamotrigine – April 2021
- Clinical Review: Recommendations for the Tapering of Benzodiazepines – March 2021
- Clinical Review: Recommendations for the Management of Acute Dental Pain – January 2021
- Drug Safety Communication: Stronger Warning Labels for Benzodiazepines – October 2020
- 2020 Immunization Updates: Vaccination during COVID-19, Flu, HepA, and Tdap – September 2020
- Clinical Review: 2020 Standards of Care for Treatment of Type 2 Diabetes – August 2020
- Clinical Guideline: Reproductive Health in Rheumatic and Musculoskeletal Diseases – May 2020
- Improving Quality of Care: Update of Risks Associated with Use of Fluoroquinolones – April 2020
- Drug Safety Communication: Withdrawal of All Ranitidine Products – April 2020
- Drug Safety Communication: Mental Health Side Effects from Montelukast – March 2020
- Improving the Quality of Care: Risks Associated with Use of Gabapentin – December 2019
- Alert: New Global Guidelines for the Treatment of Asthma – October 2019
- 2019 Immunization Updates: Flu, HepA, HPV, Measles, CA School Requirements – September 2019
- Clinical Review Update: Concomitant Anticholinergic and Antipsychotic Use – August 2019
Carve Out Medications for Medi-Cal Members
Procedures for Fee-for-Service reimbursement for carved-out medications for Medi-Cal members, such as antipsychotics, HIV medications and coagulation factors, can be found on the Medi-Cal website. The complete list of carved-out medications can be found by viewing the Managed Care Plan: County Organized Health System .
For information on how to obtain reimbursement for compounded drugs, please see Policy 403-1135 – Compounded Drugs Requiring Special Handling.
Drug Waste Reimbursement
For information on billing for drug waste, please see Policy 403-1146 –Drug Waste Reimbursement.
Enteral Nutrition Product Benefit
The Alliance covers oral nutritional supplements and enteral formulas for Medi-Cal eligible members when medically necessary. Prior authorization is required for all enteral nutrition products, including nutrition support (tube feed) formulas, oral nutrition supplements and specialty infant formulas. Prior authorization requests can be submitted by the prescribing or servicing provider and may be submitted via the Provider Portal or fax.
Please include the following when submitting a Prior Authorization:
- Copy of prescribing provider’s prescription.
- Completed Prior Authorization request form.
- Recent chart notes that address medical justification as to why the member is unable to meet his/her nutritional needs with standard or fortified foods.
- Growth charts for pediatric members or relevant weight history for adult members.
The criteria the Alliance uses to review authorization requests for medical necessity is outlined in the “Enteral Nutrition Products” section of the Medi-Cal Part 2 Pharmacy Provider Manual and further defined in Appendix A of Policy 403-1136 – Enteral Nutrition Products. For a list of covered products, please see the Medi-Cal Enteral Formulary.
Medical Nutrition Therapy
The Alliance will cover Medical Nutrition Therapy (MNT) for medically necessary conditions when prescribed by the Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Physician’s Assistant (PA), Nurse Practitioner (NP), Registered Dietitian (RD) or non-contracted provider. In order for a provider to receive payment for services rendered, a Prior Authorization is required, and services must be administered by a Registered Dietitian. A Treatment Authorization Request must be submitted for authorization via the Provider Portal, or fax to the Prior Authorizations Department at 831-430-5850 or 831-430-5515 for local referrals. For any questions, contact the Alliance Registered Dietitian at 831-430-5507.
The Alliance’s Pharmacy Home Program (PHP) promotes safe medication use and prevents harm resulting from intentional or unintentional misuse. This program helps reduce potential and actual prescription drug fraud and/or abuse by requiring a member to utilize one pharmacy to fill their PCP-selected drug class.
You may enroll an Alliance member into the PHP program by one of these methods:
- Complete the Pharmacy Home Program Enrollment Form.
- Call the Alliance Pharmacy Department at 831-430-5507.
The following medication and education resources apply across all health plans.
Quick Reference Guides
Contact the Pharmacy Department
Please contact the Alliance Pharmacy department at:
Phone: 831-430-5507 Fax at 831-430-5851
Monday-Friday, 8 a.m. to 5 p.m.
Contact Pharmacy Department
Monday-Friday, 8 a.m. to 5 p.m.
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