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Home > For Providers > Manage Care > Pharmacy Services > Pharmacy Forms

Manage Care

Pharmacy Forms

Pharmacy Services

The Alliance’s Pharmacy philosophy is directed by community standards of best medical practice.

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

Skip to content Find a Doctor Nurse Line Provider Portal Contact Us aA Accessibility ToolsGrayscaleAAA Search Search For Members Get Started Member ID Card Find a Doctor Alliance Alternative Access Standards About Your Health Plan Frequently Asked Questions Get Care Primary Care Approvals for Care Nurse Advice Line Prescriptions Medi-Cal Prescriptions Alliance Care IHSS Prescriptions […]

Hyaluronic Acid Derivatives Prior Authorization Information Request

Please fax this completed form, along with the Prior Authorization Form/TAR, to the Alliance Pharmacy Department at (831) 430-5851.

Drug Recalls and Withdrawals

Pharmacist

Learn about the different types of drug recalls and withdrawals and how to stay informed when the FDA or a company issues a recall.

Additional Pharmacy Information

For information on drug utilization review and medication and sharps disposal, visit our Additional Pharmacy Information page.

Physician-Administered Drugs (for Medi-Cal and IHSS)

Visit the Physician-Administered Drugs page for information on prior authorization criteria, drugs carved out to fee-for-service Medi-Cal, submitting authorization requests, continuity of care for new members, and billing and reimbursement.

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Phone: 831-430-5507
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Pharmacy Resources

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Latest Provider News

Provider Digest | Issue 75

Provider Digest | Issue 75

July 30, 2025
New Grievance Response Template

New Grievance Response Template

July 17, 2025
Provider Digest | Issue 74

Provider Digest | Issue 74

July 16, 2025
Give us your feedback – take the Provider Satisfaction Survey!

Give us your feedback – take the Provider Satisfaction Survey!

July 15, 2025
Join us for a D-SNP Provider Orientation with DHCS and the Alliance

Join us for a D-SNP Provider Orientation with DHCS and the Alliance

July 10, 2025

Contact us | Toll free: 800-700-3874

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