Skip to content Find a Doctor Nurse Line Provider Portal Contact Us EnglishHmongSpanish aA Accessibility ToolsGrayscaleAAA English Hmong Spanish Search For Members Get Started Member ID Card Find a Doctor Alliance Alternative Access Standards About Your Health Plan Frequently Asked Questions Mariposa and San Benito Get Care Primary Care Approvals for Care Nurse Advice Line Prescriptions Medications and Your Health Introducing Medi-Cal Rx Urgent Care Urgent Visit Access – Merced County Urgent Visit Access – Monterey County Urgent Visit Access – Santa Cruz County Behavioral Health Transportation Services Enhanced Care Management and Community Supports Other Services Dental and Vision Family Planning Medical Equipment Out-of-Area Services Member Services Access Your Health Information COVID-19 Information General COVID-19 Information COVID-19 Testing and Treatment COVID-19 Vaccine Information Language Assistance File a Grievance California Children’s Services Join an Advisory Group Member Services Advisory Group (MSAG) Member Services Advisory Group Application Whole Child Model Family Advisory Committee (WCMFAC) Member News Online Self-Service Replace ID Card Choose Primary Doctor Insurance Information Update Contact Information Information Release Privacy Request Request Personal Representative Member Reimbursement Claim Form Member Online Account Confidential Communications Request Form Find a Form Health and Wellness Health Rewards Program Wellness Resources For Providers Join Our Network Why Join How to Join Provider Application Request Provider Credentialing Applications and Policies Re-Credentialing New Provider Orientation Manage Care Behavioral Health California Children’s Services Clinical Resources Care Management Complex Case Management and Care Coordination Pain Management and Substance Use Resources Seniors and Disabilities Nurse Advice Line Referrals and Authorizations Telehealth Services Cultural and Linguistic Services Face-to-Face Interpreter Request Form Interpreter Services Provider Quick Reference Guide Tips For Working With Interpreters Interpreter Services Quality Assurance Form A to Z Glossary of Spanish & Hmong Terms Promoting Cultural and Linguistic Competency Enhanced Care Management and Community Supports Enhanced Care Management (ECM) Community Supports (CS) ECM/CS Referrals ECM/CS Trainings Health Education and Disease Management Health Education Programs Breastfeeding Support and Breast Pump Benefit Disease Management Programs Health Resources Pharmacy Medi-Cal Rx Pharmacy Formulary Prescription Drug Prior Authorization Prior Authorization Criteria Prior Authorization Information Request for Injectable Drugs Synagis Statement of Medical Necessity Treatment Authorization Request (TAR) Medical Nutrition Therapy Benefit Quick Reference Guide Quality of Care Care-Based Incentive Care-Based Incentive Resources Care-Based Incentive (CBI) Summary CBI Technical Specifications Antidepressant Medication Management Tip Sheet Immunizations: Adult – Exploratory Measure Tip Sheet Immunizations: Adolescents Tip Sheet Programmatic Measure Benchmarks & Performance Improvement Asthma Medication Ratio Tip Sheet 90-Day Referral Completion – Exploratory Tip Sheet Antidepressant Medication Management Tip Sheet Application of Fluoride Varnish Tip Sheet Immunizations: Children (Combo 10) Tip Sheet Chlamydia Screening in Women – Exploratory Measure Tip Sheet Child and Adolescent Well-Care Visits Tip Sheet Cervical Cancer Screening Tip Sheet Child and Adolescents BMI Assessment Tip Sheet Breast Cancer Screening Tip Sheet Well-Child Visits in the First 15 Months of Life Tip Sheet Unhealthy Alcohol Use in Adolescents and Adults Tip Sheet Tuberculosis (TB) Risk Assessment – Exploratory Tip Sheet Preventable Emergency Visits Tip Sheet Maximizing Your Value-Based Payments using CPT Category II Coding Tip Sheet Maternity Care: Prenatal Tip Sheet Maternity Care: Postpartum Tip Sheet Plan All-Cause Readmissions Tip Sheet Lead Screening in Children – Exploratory Measure Tip Sheet Initial Health Assessment Tip Sheet Diabetic HbA1c Poor Control >9% Tip Sheet Developmental Screening in the First 3 Years Tip Sheet Controlling High Blood Pressure – Exploratory Measure Tip Sheet Immunizations: Children (Combo 10) Tip Sheet Best Practices for Reducing Patient No-Shows Tip Sheet Ambulatory Care Sensitive Admissions Tip Sheet Depression Tool Kit USPSTF Recommendations for Primary Care Practice Preventable Emergency Care Visit Diagnosis Tip Sheet Blood Lead Testing Flyer California Management Guidelines: Childhood Lead Poisoning Standard of Care Guidelines: Childhood Lead Poisoning Adverse Childhood Experiences (ACEs) Screening in Children and Adolescents Tip Sheet Screening for Depression and Follow-Up Plan Tip Sheet What’s New Health Assessments Initial Health Appointment Billing Code List HEDIS HEDIS Resources Behavioral Health Measures Child and Adolescent Health Measures Chronic and Persistent Conditions Health Measures Women’s Health Measures HEDIS Code Set HEDIS FAQ Guide Immunization Resources Member Incentives Site Reviews Facility Site Review Infection Control: Spore Testing Job Aid DHCS Facility Site Review (FSR) Checklist FSR Critical Elements: Interim Monitoring Form Medical Record Review DHCS Medical Record Review (MRR) Checklist Physical Accessibility Review Survey Value-Based Payments Resources COVID-19 Claims View/Submit a Claim Forms Provider Directory Update Form News Provider Directory Provider Manual All Plan Letters Timely Access to Care Webinars and Training Provider Events Calendar Provider Portal Using the Provider Portal Frequently Asked Questions Provider Portal User Guide Provider Portal Quick Reference Provider Portal Account Request Form Procedure Code Lookup Tool Provider news you can useCheck out the September Provider Bulletin! For Communities Healthy Communities Your Health Matters Community Events Community-Based Adult Services Community Health Worker Benefit Community Resources Doula Services Benefit Enhanced Care Management and Community Supports Medi-Cal Capacity Grants Access to Care Equity Learning for Health Professionals Program Healthcare Technology Program Workforce Recruitment Programs CHW Recruitment Program MA Recruitment Program Provider Recruitment Program Healthy Beginnings Home Visiting Program Parent Education and Support Program Healthy Communities Community Health Champions Partners for Active Living Program Partners for Healthy Food Access Program How to Apply Grants at Work Community Publications Community Impact Reports The Beat E-Newsletter Don’t miss a beatSubscribe to our community newsletter The Beat Health Plans Medi-Cal Alliance Care IHSS Alliance Care IHSS Price Transparency Tool Update your Medi-CalMake sure you’re covered! About Us About the Alliance Fact Sheet Mission, Vision and Values Strategic Plan 2022-2026 Leadership Public Meetings Careers Contact Us News Community News Member News Provider News Meetings and Events Newsroom Committed to health equitySee our work toward equitable health care for our members. For Members Get Started Member ID Card Find a Doctor Alliance Alternative Access Standards About Your Health Plan Frequently Asked Questions Mariposa and San Benito Get Care Primary Care Approvals for Care Nurse Advice Line Prescriptions Medications and Your Health Introducing Medi-Cal Rx Urgent Care Urgent Visit Access – Merced County Urgent Visit Access – Monterey County Urgent Visit Access – Santa Cruz County Behavioral Health Transportation Services Enhanced Care Management and Community Supports Other Services Dental and Vision Family Planning Medical Equipment Out-of-Area Services Member Services Access Your Health Information COVID-19 Information General COVID-19 Information COVID-19 Testing and Treatment COVID-19 Vaccine Information Language Assistance File a Grievance California Children’s Services Join an Advisory Group Member Services Advisory Group (MSAG) Member Services Advisory Group Application Whole Child Model Family Advisory Committee (WCMFAC) Member News Online Self-Service Replace ID Card Choose Primary Doctor Insurance Information Update Contact Information Information Release Privacy Request Request Personal Representative Member Reimbursement Claim Form Member Online Account Confidential Communications Request Form Find a Form Health and Wellness Health Rewards Program Wellness Resources For Providers Join Our Network Why Join How to Join Provider Application Request Provider Credentialing Applications and Policies Re-Credentialing New Provider Orientation Manage Care Behavioral Health California Children’s Services Clinical Resources Care Management Complex Case Management and Care Coordination Pain Management and Substance Use Resources Seniors and Disabilities Nurse Advice Line Referrals and Authorizations Telehealth Services Cultural and Linguistic Services Face-to-Face Interpreter Request Form Interpreter Services Provider Quick Reference Guide Tips For Working With Interpreters Interpreter Services Quality Assurance Form A to Z Glossary of Spanish & Hmong Terms Promoting Cultural and Linguistic Competency Enhanced Care Management and Community Supports Enhanced Care Management (ECM) Community Supports (CS) ECM/CS Referrals ECM/CS Trainings Health Education and Disease Management Health Education Programs Breastfeeding Support and Breast Pump Benefit Disease Management Programs Health Resources Pharmacy Medi-Cal Rx Pharmacy Formulary Prescription Drug Prior Authorization Prior Authorization Criteria Prior Authorization Information Request for Injectable Drugs Synagis Statement of Medical Necessity Treatment Authorization Request (TAR) Medical Nutrition Therapy Benefit Quick Reference Guide Quality of Care Care-Based Incentive Care-Based Incentive Resources Care-Based Incentive (CBI) Summary CBI Technical Specifications Antidepressant Medication Management Tip Sheet Immunizations: Adult – Exploratory Measure Tip Sheet Immunizations: Adolescents Tip Sheet Programmatic Measure Benchmarks & Performance Improvement Asthma Medication Ratio Tip Sheet 90-Day Referral Completion – Exploratory Tip Sheet Antidepressant Medication Management Tip Sheet Application of Fluoride Varnish Tip Sheet Immunizations: Children (Combo 10) Tip Sheet Chlamydia Screening in Women – Exploratory Measure Tip Sheet Child and Adolescent Well-Care Visits Tip Sheet Cervical Cancer Screening Tip Sheet Child and Adolescents BMI Assessment Tip Sheet Breast Cancer Screening Tip Sheet Well-Child Visits in the First 15 Months of Life Tip Sheet Unhealthy Alcohol Use in Adolescents and Adults Tip Sheet Tuberculosis (TB) Risk Assessment – Exploratory Tip Sheet Preventable Emergency Visits Tip Sheet Maximizing Your Value-Based Payments using CPT Category II Coding Tip Sheet Maternity Care: Prenatal Tip Sheet Maternity Care: Postpartum Tip Sheet Plan All-Cause Readmissions Tip Sheet Lead Screening in Children – Exploratory Measure Tip Sheet Initial Health Assessment Tip Sheet Diabetic HbA1c Poor Control >9% Tip Sheet Developmental Screening in the First 3 Years Tip Sheet Controlling High Blood Pressure – Exploratory Measure Tip Sheet Immunizations: Children (Combo 10) Tip Sheet Best Practices for Reducing Patient No-Shows Tip Sheet Ambulatory Care Sensitive Admissions Tip Sheet Depression Tool Kit USPSTF Recommendations for Primary Care Practice Preventable Emergency Care Visit Diagnosis Tip Sheet Blood Lead Testing Flyer California Management Guidelines: Childhood Lead Poisoning Standard of Care Guidelines: Childhood Lead Poisoning Adverse Childhood Experiences (ACEs) Screening in Children and Adolescents Tip Sheet Screening for Depression and Follow-Up Plan Tip Sheet What’s New Health Assessments Initial Health Appointment Billing Code List HEDIS HEDIS Resources Behavioral Health Measures Child and Adolescent Health Measures Chronic and Persistent Conditions Health Measures Women’s Health Measures HEDIS Code Set HEDIS FAQ Guide Immunization Resources Member Incentives Site Reviews Facility Site Review Infection Control: Spore Testing Job Aid DHCS Facility Site Review (FSR) Checklist FSR Critical Elements: Interim Monitoring Form Medical Record Review DHCS Medical Record Review (MRR) Checklist Physical Accessibility Review Survey Value-Based Payments Resources COVID-19 Claims View/Submit a Claim Forms Provider Directory Update Form News Provider Directory Provider Manual All Plan Letters Timely Access to Care Webinars and Training Provider Events Calendar Provider Portal Using the Provider Portal Frequently Asked Questions Provider Portal User Guide Provider Portal Quick Reference Provider Portal Account Request Form Procedure Code Lookup Tool Provider news you can useCheck out the September Provider Bulletin! For Communities Healthy Communities Your Health Matters Community Events Community-Based Adult Services Community Health Worker Benefit Community Resources Doula Services Benefit Enhanced Care Management and Community Supports Medi-Cal Capacity Grants Access to Care Equity Learning for Health Professionals Program Healthcare Technology Program Workforce Recruitment Programs CHW Recruitment Program MA Recruitment Program Provider Recruitment Program Healthy Beginnings Home Visiting Program Parent Education and Support Program Healthy Communities Community Health Champions Partners for Active Living Program Partners for Healthy Food Access Program How to Apply Grants at Work Community Publications Community Impact Reports The Beat E-Newsletter Don’t miss a beatSubscribe to our community newsletter The Beat Health Plans Medi-Cal Alliance Care IHSS Alliance Care IHSS Price Transparency Tool Update your Medi-CalMake sure you’re covered! About Us About the Alliance Fact Sheet Mission, Vision and Values Strategic Plan 2022-2026 Leadership Public Meetings Careers Contact Us News Community News Member News Provider News Meetings and Events Newsroom Committed to health equitySee our work toward equitable health care for our members. Home > For Providers > Manage Care > Pharmacy Services > Prior Authorization Information Request for Injectable Drugs Manage Care 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. Click image below to open PDF file: Contact Pharmacy Department Phone: 831-430-5507 Fax: 831-430-5851 Monday-Friday, 8 a.m. to 5 p.m. Provider Resources Provider Portal Provider Directory Provider Manual Procedure Code Lookup Tool Latest Provider News 2023-2024 palivizumab (Synagis®) authorization guidelines September 28, 2023 Get support applying for DHCS Equity and Practice Transformation grants September 22, 2023 Spread the word: Merced Community Health Fair + flu clinic happens Oct. 8 September 20, 2023 Provider Digest | Issue 33 September 18, 2023 Provider training series on Adverse Childhood Experiences September 13, 2023 Contact us | Toll free: 800-700-3874