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Effective January 1, 2022, all pharmacy services billed as a pharmacy claim are transitioned from the Alliance pharmacy benefit to Medi-Cal Rx, a Medi-Cal Fee-For-Service (FFS) program, including:
- Outpatient drugs (prescription and over-the-counter).
- Physician-Administered Drugs (PADs).
- Enteral nutritional products.
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Medi-Cal Rx will not include pharmacy services billed as a medical (professional) or institutional claim. For Physician-Administered Drugs billed as a medical claim, see Physician-Administered Drugs.
Beginning January 1, 2022, pharmacy services will transition from Medi-Cal managed care health plans into the fee-for-service delivery system. The California Department of Health Care Services (DHCS) anticipates this transition will standardize the Medi-Cal pharmacy benefit statewide, improve access to pharmacy services and strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.
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Members must obtain their prescribed drugs from a pharmacy that is in the Medi-Cal Rx pharmacy network. A list of pharmacies is available on the Medi-Cal Rx tus vas sab or by calling the Medi-Cal Rx Contractor, Magellan Medicaid Administration, Inc., at 800-977-2273.
Members need to bring their Benefits Identification Card (BIC) from Medi-Cal to the pharmacy with their prescriptions. Alliance identification cards cannot be used for Medi-Cal Rx billing.
|Medi-Cal Rx Lub Tsev Ua Hauj Lwm Ua Hauj Lwm Pab Cuam Qhua 1-800-977-2273|
Please note: This does not affect IHSS members. IHSS members can continue using their Alliance ID card.
The list of covered drugs for Medi-Cal Rx, or Contract Drugs List (CDL), is available on the Medi-Cal Rx tus vas sab. Certain pharmacy drugs and medical supplies may require prior authorization (PA). Prior authorization requests must be submitted to Medi-Cal Rx via one of the following methods:
- Medi-Cal Rx Provider Portal.
- CoverMyMeds® (CMM).
- Fax: 800-869-4325.
- United States (US) Mail:
Medi-Cal Rx Lub Tsev Ua Hauj Lwm Ua Hauj Lwm Pab Cuam Qhua
ATTN: Provider PA Requests
P.O. Box 730
Rancho Cordova, CA 95741-0730
- NCPDP P4 – Request Only.
Medi-Cal Rx PA Request Form and additional information are available on the Medi-Cal Rx tus vas sab or by calling Medi-Cal Rx at 800-977-2273.
Dispensing of a 72-hour emergency supply of any medication for which delaying the dispensing would withhold a medically necessary service is permitted by Medi-Cal Rx without a prior authorization. For more information, please refer to Medi-Cal Rx tus vas sab or call Medi-Cal Rx at 800-977-2273.
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Phone: 800-977-2273, 24 hours a day, 7 days a week
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The Alliance has partnered with MedImpact, a Pharmacy Benefit Manager (PBM) to process pharmacy claims and prior authorization requests for Alliance Care IHSS members.
For physician-administered drugs billed as a medical claim, see Physician-Administered Drugs.
Members must take their prescriptions to a pharmacy in MedImpact’s network. To find a pharmacy, search in MedImpact's Pharmacy Directory. For more information regarding the Alliance Pharmaceutical Services Access, please see Policy 403-1126 – Pharmaceutical Services Access.
The Alliance Formulary is a list of covered drugs developed and managed by MedImpact. Covered drugs are selected by physician and pharmacist subject matter experts who collaboratively support MedImpact’s Pharmacy and Therapeutics (P&T) Committee. To find out if a particular drug is covered, please refer to the Lub Alliance Daim Ntawv Teev Tshuaj Noj (Formulary).
Drugs that are not covered on the formulary, or drugs on the formulary with restrictions such as prior authorization (PA), step therapy or quantity limits may require prior authorization review to determine coverage for medical necessity. Prior authorization requests must be submitted to MedImpact, not to the Alliance.
If faxed or mailed, prior authorization requests must be submitted on the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (California Form 61-211). Submissions on other forms will not be accepted.
Submitting a Prior Authorization
PA requests must be submitted to MedImpact via the following methods:
- Fax: 858-790-7100.
- MedImpact ePA Program.
- United States (US) Mail:
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
Additional information is available on MedImpact website or by calling MedImpact at 800-788-2949.
24-hour access is provided by any 24-hour pharmacy that contracts with the Alliance’s Pharmacy Benefit Manager (PBM), MedImpact. Currently, access to 24-hour pharmacies is available in Santa Cruz (Freedom) and Monterey (Salinas and Seaside) counties. To find a pharmacy, search in MedImpact's Pharmacy Directory.
MedImpact is authorized to enter an override for five-day emergency supply of any medication 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 MedImpact. MedImpact can be reached at 800-788-2949.
The Alliance has a specialty pharmacy network called MedImpact Direct Specialty. The specialty drugs are required to be filled at a pharmacy in MedImpact Direct Specialty network. These specialty drugs are shown on the formulary with an “SP” symbol.
Prescription referrals for specialty medications need to be sent to MedImpact Direct Specialty. MedImpact Direct Specialty will send referrals, along with the member’s benefit and eligibility information, to a network specialty pharmacy.
How to Submit Specialty Referrals
Fax the MedImpact Direct Specialty referral form copy of the patient's insurance card and lab work, if appropriate, to 888-807-5716.
For any questions regarding MedImpact Direct Specialty, visit Home Delivery | MedImpact or call 877-391-1103 (Monday through Friday, 5 a.m. to 5 p.m.).
MedImpact Direct Mail Order Pharmacy has changed to Birdi: visit Home Delivery | MedImpact or call 855-873-8739. Prescriptions can be submitted electronically to Birdi or faxed to 888-783-1773.
Lub Khws muag tshuaj SortPak: visit www.sortpak.com or call 877-570-7787.
MedImpact Customer Contact Center
Some physician/facility-administered Drugs (PADs) billed as a medical claim may require prior authorization (PA) by the Alliance.
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. For more information on the authorization review process for PADs, please see Policy 403-1141 – Physician/Facility-Administered Drugs Requiring Prior Authorization.
The Alliance prefers the use of a Biosimilar over its branded biologic counterpart. For more information, please see Policy 403-1142 - Biosimilars.
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 on pages 5-9 of the MCP: County Organized Health System file. 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 lossis Treatment Authorization Request (TAR) Form for all Alliance members.
- 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 fill or per date of service (DOS) (in “quantity” field).
- Number of fills or DOS requested (in “units” field).
- 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.
In the event that 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.
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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.
The Alliance has developed policies in collaboration with internal and external stakeholders to help ensure the safe and appropriate use of opioid medications.
For Alliance Care IHSS members, the Alliance will allow refills for opioid prescriptions when greater than or equal to 90% of the days' supply of the prescription is met. The next refill request, for when less than 90% of the days' supply of an opioid prescription has elapsed, will require a prior authorization with medical justification for the early refill. For Medi-Cal members, please refer to the Medi-Cal Rx tus vas sab. For more information on the opioid utilization review process, please see Policy 403-1139 - Opioid Utilization Review.
DHCS Medi-Cal DUR Educational Articles
- Risks to Patients Exposed to Xylazine in Illicit Drugs - January 2023
- Improving the Quality of Care: Treatment of Latent Tuberculosis Infection - January 2023
- 2022 Immunization Update: Mpox, HepB, Influenza, COVID-19, Pneumococcal, Zoster - January 2023
- Removal of DATA-Waiver (X-Waiver) Requirement - January 2023
- Improving the Quality of Care: Legislative Impact on the Use of Naloxone – Updated March 2022
- Submitting Quality Data to the California Immunization Registry (CAIR2) – May 2022
- Professional Organizations Push for Recall of Buprenorphine Dental Warning – February 2022
- Improving the Quality of Care: Legislative Impact on the Use of Naloxone – December 2021
- 2021 Immunization Updates: COVID-19, Influenza, and Meningococcal Disease – September 2021
- UPDATED: Drug Safety Communication: Voluntary Recall of Varenicline (Chantix) Due to Nitrosamine – September 2021
- Drug Safety Communication: FDA Requests Removal of Pregnancy Contraindication for Statins – August 2021
- Drug Safety Communication: Voluntary Recall of Varenicline (Chantix) Due to Nitrosamine – August 2021
- 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
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 on pages 5-9 of the MCP: County Organized Health System file. 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 website in the Part 2 manual for Lub Tsev Muag Tshuaj.
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.
The Alliance 340B Pharmacy Program
For information on billing for drugs purchased under the 340B program, please see Policy 403-1145- Pharmacy 340B Program.
Enteral nutrition products and parenteral nutrition products that are billed as a pharmacy claim are transitioned from the Alliance pharmacy benefit to Medi-Cal Rx for Medi-Cal members. Enteral nutrition formulas, including nutrition support (tube feed) formulas, oral nutrition supplements and specialty infant formulas, can only be billed on a pharmacy claim. Refer to the List of Covered Enteral Nutrition Products on the Medi-Cal Rx tus vas sab. Prior authorization requests for enteral nutrition products that are billed as a pharmacy claim must be submitted to Medi-Cal Rx. For more details about Medi-Cal Rx, refer to our Medi-Cal section.
For other enteral nutrition products and parenteral nutrition products that are billed as a medical claim, prior authorization is required to be submitted to the Alliance. Prior authorization requests can be submitted by the prescribing or servicing provider and may be submitted via the Kws Kho Mob Lub Chaw Tswj Xyuas Tswvcuab Cov Ntaub Ntawv or faxed to 831-430-5851. A copy of the prescription and recent chart notes detailing the member’s diagnosis and medical necessity of the product being prescribed must be submitted. The criteria the Alliance uses to review authorization requests for medical necessity is outlined in Policy 403-1136 – Enteral Nutrition Products thiab Attachment A “Procedure and Assessment for Medical Necessity Determination of Enteral Nutrition Products".
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.
Medical Nutrition Therapy (MNT) provided by a Registered Dietitian (RD) is a covered benefit for all lines of business for members who meet qualifying conditions. The Alliance will cover 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 faxed to the Prior Authorizations Department at 831-430-5850 (831-430-5515 for local referrals). For any questions, contact the Alliance Registered Dietitian at 831-430-5507.
Providers offering MNT to Alliance members should use the following codes for authorization and claims payment:
- CPT-4 Code 97802 - MNT, initial assessment and intervention, individual, face-to-face with patient, each 15 minutes.
- CPT-4 Code 97803 - MNT, re-assessment and intervention, individual, face-to-face with patient, each 15 minutes.
- CPT-4 Code 97804 - MNT, group (2 or more individuals), each 30 minutes.
- CPT-4-Code G0270 - MNT: reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes.
- CPT-4-Code G0271 - MNT, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes.
- HCPC Code S9470 - Nutritional Counseling, dietitian visit, each 15 minutes.
- CPT-4 Code T1014 - Telehealth if applicable.
Annual MNT coverage is limited to a maximum of 3 hours for the first calendar year and 2 hours per calendar year in subsequent years. For additional MNT hours beyond the aforementioned utilization limits, a new authorization request with supporting documentation must be submitted to the Alliance for review.
Conditions include but are not limited to:
- Pediatric obesity with a BMI >95th
- Cancer with significant weight loss.
- Pre/post bariatric surgery.
- Conditions impairing digestion and absorption.
- Underweight status or unintended weight loss.
Mus xyuas ntawm Medical Nutrition Therapy Quick Reference Guide for full details. For more information and a list of qualifying conditions on MNT, please see Policy 403-1149 – Medical Nutrition Therapy.
Please contact the Alliance Pharmacy Department at:
Tus Xov Tooj: 831-430-5507 (Monday-Friday, 8 a.m. to 5 p.m., excluding holidays)
Tus Xov Tooj Xa Ntawv (Fax): 831-430-5851
After Business Hours Contacts for Prescription PA Requests
- For Medi-Cal, contact Medi-Cal Rx.
- For MedImpact, contact MedImpact.
Contact Pharmacy Department
Tus Xov Tooj: 831-430-5507
Tus Xov Tooj Xa Ntawv (Fax): 831-430-5851
Hnub Monday-hnub Friday, 8 a.m. txog 5 p.m.
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