Pharmacy Forms
The Alliance’s Pharmacy philosophy is directed by community standards of best medical practice.
Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members.
Use this form for chemotherapy, HCPCS J-code requests and other IV medication requests administered by the physician/hospital.
Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.
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Please fax this completed form, along with the Prior Authorization Form/TAR, to the Alliance Pharmacy Department at (831) 430-5851.
Learn about the different types of drug recalls and withdrawals and how to stay informed when the FDA or a company issues a recall.
For information on drug utilization review and medication and sharps disposal, visit our Additional Pharmacy Information page.
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.
The Alliance has partnered with MedImpact, a Pharmacy Benefit Manager (PBM), to process pharmacy claims and prior authorization requests for Alliance Care IHSS members.
Contact Pharmacy Department
Phone: 831-430-5507
Fax: 831-430-5850
Monday-Friday, 8 a.m. to 5 p.m.
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