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

Prior authorization (PA) criteria are based on the recommendations of the Pharmacy and Therapeutics Committee. If a physician-administered drug requiring prior authorization has no PA criteria, it will be reviewed for medical necessity based upon Alliance policies, as well as nationally recognized standards.

Exceptions for PADs that are not on the Physician-Administered Drug List, do not meet restrictions or exceed the limits will require a prior authorization and will be reviewed for medical necessity. For more information on the authorization review process for PADs, please see Policy 403-1141 – Physician/Facility-Administered Drugs Requiring Prior Authorization.

Biosimilar

The Alliance prefers the use of a Biosimilar over its branded biologic counterpart. For more information, please see Policy 403-1142 - Biosimilars.

Synagis

For providers who wish to administer Synagis in their office, the Synagis Statement of Medical Necessity Form must 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.

For Medi-Cal members, the Alliance does not cover drugs used for treatment of HIV/AIDS/Hepatitis B, alcohol and heroin detoxification and dependency, clotting factor disorder and antipsychotic drugs listed under “Capitated/Noncapitated Drugs” in the MCP: County Organized Health System (COHS) section in Part 1 of the Medi-Cal Provider Manual. These carved-out or non-capitated drugs should be billed to Fee-For-Service (FFS) Medi-Cal. For more information, see the Billing and Reimbursement section.

Authorization requests for physician-administered drugs billed as a medical claim may be submitted to the Alliance via the methods listed below. Submission of PA requests is preferred through the Alliance Portal. If faxed or mailed, prior authorization requests must be submitted on the Prescription Drug Prior Authorization Request Form. Requests submitted on other forms will be voided.

Submit authorization requests for physician-administered drugs billed as a medical claim via:

• The Alliance Provider Portal (preferred).
• Fax: 831-430-5851.
• United States (US) 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’s 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, NPI, address, phone number and fax number.
• Servicing provider name, NPI, address, phone number and fax number (if different from prescriber).
• 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 administration or per date of service (DOS).
• Number of administration 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 preferred alternatives 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.

For more information on the authorization review process, please see Policy 403-1103 – Pharmacy Authorization Request Review Process.

• Prescription Drug Prior Authorization Request Form.
• Treatment Authorization Request (TAR) Form (PADs only).

In the following cases, include forms specific to a therapeutic class or drug with the above PA or TAR forms or Alliance Portal submission. Submitting this additional information makes the review process quicker and more efficient.

• 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.
• 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 Policy 403-1120 – Synagis.

If new members are being treated with a drug at the time of their enrollment with the plan, the Alliance will work with Alliance providers to ensure that members 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.

Billing and Reimbursement for Drugs Carved Out to Fee-For-Service Medi-Cal

For Medi-Cal members, the Alliance does not cover drugs used for treatment of HIV/AIDS/Hepatitis B, alcohol and heroin detoxification and dependency, clotting factor disorder and antipsychotic drugs listed under "Capitated/Noncapitated Drugs" in the MCP: County Organized Health System (COHS) section in Part 1 of Medi-Cal Provider Manual. These carved-out or non-capitated drugs should be billed to Fee-For-Service (FFS) Medi-Cal. Procedures for Fee-For-Service reimbursement for carved-out drugs can be found on the Medi-Cal Provider Manual.

Drug Waste Reimbursement

For information on billing for drug waste, please see Policy 403-1146 – Drug Waste Reimbursement.

The Alliance 340B Pharmacy Program

For information on billing for drugs purchased under the 340B program, please see Policy 403-1145- Pharmacy 340B Program.