Tus kws kho mob-tswj tshuaj (rau Medi-Cal thiab IHSS)

Kev tso cai ua ntej (PA). 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 – Tus kws kho mob/Facility-Administered Drugs Yuav tsum tau kev tso cai ua ntej.

Biosimilar

Lub Alliance nyiam siv Biosimilar tshaj nws cov khoom lag luam biologic counterpart. Yog xav paub ntxiv, thov mus saib Txoj Cai 403-1142 - Biosimilars.

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) seem nyob rau hauv Tshooj 1 ntawm Phau Ntawv Qhia Medi-Cal. Cov tshuaj carved-out los yog tsis-capitated cov tshuaj no yuav tsum tau them rau Fee-For-Service (FFS) Medi-Cal. Yog xav paub ntxiv, saib lub Nqe Kev Them Nqi thiab Them Rov Qab.

Daim ntawv tso cai thov rau cov kws kho mob-tswj tshuaj uas tau sau nqi raws li a kev thov kho mob tuaj yeem xa mus rau Alliance los ntawm cov txheej txheem hauv qab no. Kev xa daim ntawv thov PA yog nyiam los ntawm Alliance Portal. Yog faxed los yog xa ntawv, thov kev tso cai ua ntej yuav tsum tau xa rau ntawm Daim Ntawv Thov Kev Tso Cai Siv Tshuaj Ua Ntej. Requests submitted on other forms will be voided.

Xa daim ntawv thov kev tso cai rau tus kws kho mob-tswj tshuaj uas tau them raws li daim ntawv thov kev kho mob los ntawm:

• Lub Alliance Provider Portal (xav tau).
• Tus Fax: 831-430-5851.
• Teb Chaws Asmeskas (US) Mail:
  Central California Alliance for Health
  Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv - Pharmacy
  PO Box 660012
  Scotts Valley, CA 95067-0012

Yog tias koj muaj lus nug txog kev thov kev tso cai sai sai, thov hu rau Alliance Pharmacy Department ntawm 831-430-5507 lossis 800-700-3874, ext. 5507. Cov sijhawm ua haujlwm yog hnub Monday-Friday, 8 teev sawv ntxov txog 5 teev tsaus ntuj, tsis suav cov hnub so.

Txhawm rau ua tiav daim ntawv thov kev tso cai ua ntej, all ntawm cov ntaub ntawv hauv qab no yuav tsum tau muab:

• Tus tswv cuab lub npe, tus lej ID thiab DOB.
• Thov tus kws kho mob lub npe thiab cov ntaub ntawv tiv tauj.
• Cov lus piav qhia ntawm cov tshuaj thov los yog yam khoom. Koj yuav tsum suav nrog Healthcare Common Procedure Coding System (HCPCS) code yog hais tias thov ib tug kws kho mob lossis chaw muab tshuaj.
• Tus kws kho mob lub npe, NPI, chaw nyob, tus xov tooj thiab tus xov tooj fax.
• Tus kws kho mob lub npe, NPI, chaw nyob, tus xov tooj thiab tus fax xov tooj (yog tias txawv ntawm tus kws kho mob).
• Kev kuaj mob (lossis ICD code) uas feem ntau piav qhia qhov tseeb rau cov tshuaj. Thov suav tag nrho cov kev kuaj mob ntsig txog kev kho mob rau kev tshuaj xyuas.
• Quantity requested per administration or per date of service (DOS).
• Number of administration or DOS requested.
• Cov lus qhia rau kev siv.
• Lub sijhawm xav tau ntawm kev kho mob.
• Cov ntaub ntawv ntawm cov ntaub ntawv kho mob tsim nyog uas txhawb nqa qhov tsim nyog kho mob ntawm cov tshuaj thov lossis cov khoom, suav nrog:
  • Lwm yam tshuaj los yog kev kho mob rau qhov kev qhia no uas twb tau sim thiab ua tsis tiav. Thov suav nrog cov txiaj ntsig tau li cas.
  • Vim li cas cov kev xaiv uas nyiam siv tsis tuaj yeem siv.
  • Txhua yam ntaub ntawv ntxiv los txhawb kev kuaj mob thiab kev kho mob kom raug, xws li kev kuaj pom thiab cov kws kho mob tshwj xeeb.

Cov ntaub ntawv tsis tiav thiab/lossis tsis raug cai yuav raug tsis lees paub lossis muab pov tseg.

Yog xav paub ntxiv txog cov txheej txheem tshuaj xyuas kev tso cai, thov saib Txoj Cai 403-1103 – Pharmacy Authorization Request Process Review.

• Daim Ntawv Thov Kev Tso Cai Siv Tshuaj Ua Ntej.

In the following cases, include forms specific to a therapeutic class or drug with the above PA form or Alliance Portal kev xa. Kev xa cov ntaub ntawv ntxiv no ua rau cov txheej txheem tshuaj xyuas sai dua thiab ua haujlwm tau zoo.

• Cov ntaub ntawv tso cai ua ntej thov rau Cov Tshuaj Txhaj Tshuaj: Siv daim foos no rau kev kho mob, HCPCS J-code thov thiab lwm yam kev thov tshuaj IV uas tau tswj hwm los ntawm tus kws kho mob / tsev kho mob.

Yog tias cov tswvcuab tshiab raug kho nrog tshuaj thaum lub sijhawm lawv tso npe nrog txoj kev npaj, Alliance yuav ua haujlwm nrog Alliance cov kws kho mob kom ntseeg tau tias cov tswvcuab tau txais kev saib xyuas txuas ntxiv nrog lawv cov kev pabcuam tshuaj.

Yog xav paub ntxiv txog kev saib xyuas txuas ntxiv rau cov tswv cuab tshiab, thov saib Txoj Cai 403-1114 – Kev Kho Mob Ntxiv rau Cov Tswv Cuab Tshiab.

Kev Them Nqi thiab Kev Them Nyiaj Rov Qab Rau Cov Tshuaj Txhaum Cai Rau Tus Nqi-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) ntu hauv Tshooj 1 ntawm Medi-Cal Phau Ntawv Qhia. Cov tshuaj carved-out los yog tsis-capitated cov tshuaj no yuav tsum tau them rau Fee-For-Service (FFS) Medi-Cal. Cov txheej txheem rau Nqi-Rau-Service reimbursement rau carved-out tshuaj muaj nyob rau ntawm Medi-Cal Provider Manual.

Kev them nyiaj rov qab siv tshuaj pov tseg

Yog xav paub txog kev them nqi tshuaj pov tseg, thov saib Txoj Cai 403-1146 – Kev them nyiaj rov qab rau cov tshuaj khib nyiab.

Alliance 340B Pharmacy Program

Yog xav paub txog kev them nqi rau cov tshuaj yuav nyob rau hauv qhov kev pab cuam 340B, thov mus saib Txoj Cai 403-1145- Pharmacy 340B Program.