Use this form to submit prescription drug prior authorization requests for Alliance Care IHSS members.
Providers who wish to administer Synagis in their office are required to submit the Statement of Medical Necessity along with the prior authorization request.
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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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.