See billing +Rx updates, member assistance and more!
Sharing immigration and health care resources with members
The Alliance is sharing updated resources to help members navigate immigration and health care concerns. These include information about Medi-Cal eligibility, local and state legal aid, and support programs available regardless of immigration status. Key points for members:
- Medi-Cal eligibility remains unchanged — all who qualify can still receive coverage.
- Starting January 2026, some members’ health care benefits and access may change.
- Members should continue seeing their doctor for needed care.
To make it easier for members to access care from home, we’re promoting multiple no-cost telehealth options:
- Their own doctor, if phone or video visits are offered.
- Alliance Nurse Advice Line (844-971-8907).
- Rocket Doctor (844-996-3763 or online).
- Zócalo Health (213-855-3465 or online).
Provider request: If your practice offers phone or video visits, please notify your Provider Relations Representative. We will share this information with members who call to request a provider that offers telehealth services. For the full list of immigration and health care resources, including county-specific programs, visit the Immigration Help page on the Alliance website. If you have questions or updates to share, contact a Provider Relations Representative at 800-700-3874, ext. 5504.
New webinar: How Cal-MAP equips providers to address youth mental health
Attend an upcoming webinar about the California Child and Adolescent Mental Health Access Portal (Cal-MAP) on Thursday, Sept. 4 from noon to 1 p.m. This webinar is part of the Implementation with Intention training series. Cal-MAP is a no-cost consultation program that supports primary care and school-based providers in delivering timely, high-quality mental health care to youth ages 0–25. In this webinar, we will provide an overview of Cal-MAP’s services, including consultation on screening, diagnosis and treatment from child psychiatrists, as well as resource and referral guidance from licensed social workers.
Details
- When: Thursday, Sept. 4, 2025, from noon to 1 p.m.
- Where: Online.
- Register: Register online.
Key topics
- How Cal-MAP expands access to youth mental health care.
- How to use the Cal-MAP portal and service offerings to support children, youth and families impacted by ACEs, toxic stress and other behavioral health issues.
- Learn about clinical impacts that have been identified by Cal-MAP users.
- Identify resources for providers and families based on specific topics or mental health concerns.
Speaker: Petra Steinbuchel, MD
Physician-administered drug changes to know, effective Sept. 1, 2025
The Alliance has made changes to physician administered drug benefits. You can find prior authorization (PA) criteria on our website. The changes are as follows:
| HCPCS Code | Drug | Change | Preferred Drug |
| J0750 | Emtricitabine 200Mg And Tenofovir Disoproxil Fumarate 300Mg (Truvada) | Increased quantity limit | |
| J0751 | Emtricitabine 200Mg And Tenofovir Alafenamide 25Mg (Descovy) | Increased quantity limit | |
| J3299 | Triamcinolone Acetonide (Xipere) | New PA Criteria | Kenalog, Triesence |
| J7312 | Dexamethasone (Ozurdex) | Update PA Criteria | Kenalog, Triesence |
| J7313 | Fluocinolone Acetonide (Iluvien) | Update PA Criteria | Kenalog, Triesence |
| J7314 | Fluocinolone Acetonide (Yutiq) | Update PA Criteria | Kenalog, Triesence |
| J7311 | Fluocinolone Acetonide (Retisert) | Update PA Criteria | Kenalog, Triesence |
| J7351 | Bimatoprost (Durysta) | New PA Criteria | Bimatoprost, Latanoprost |
| J7355 | Travoprost (iDose TR) | New PA Criteria | Bimatoprost, Latanoprost |
| J2782 | Avacincaptad Pegol (Izervay) | New PA Criteria | |
| J2781 | Pegcetacoplan (Syfovre) | New PA Criteria |
The Alliance has updated the following pharmacy policies. To request a copy, please call the Alliance Pharmacy Department at 831-430-5507.
- 403-1114 Continuing Pharmacy Care for New Members.
- 403-1123 Drugs for the Treatment of Sexual or Erectile Dysfunction.
- 403-1124 Drug-Recall Procedure.
- 403-1126 Pharmaceutical Services Access.
- 403-1128 Other Non-Formulary Drugs.
- 403-1137 Drugs Previously Approved by the Alliance.
- 403-1139 Opioid Utilization Review.
- 403-1143 Drug Utilization Review.
- 403-1144 Pharmacy Provision of Family Planning Services.
- 403-1145 Pharmacy 340B Program.
- 403-1147 CCS Pharmaceuticals Policy.
- 403-1148 Mail Order Pharmacy Services.
- 403-1152 Site of Care.
- 403-1153 Botulinum Toxin for Spasticity and Dystonia in Children.
- 403-1155 Beyfortus (Nirsevimab).
2025-2026 Influenza season billing + coding updates
Vaccine composition for the 2025-26 U.S. influenza season
The FDA recommends that the trivalent formulation of egg-based influenza vaccines for the 2025-2026 U.S. influenza season contain the following:
- An A/Victoria/4897/2022 (H1N1) pdm09-like virus.
- An A/Croatia/10136RV/2023 (H3N2)-like virus.
- A B/Austria/1359417/2021 (B/Victoria lineage)-like virus.
The FDA recommends that the trivalent formulation of cell- or recombinant-based influenza vaccines for the 2025-2026 U.S. influenza season contain the following:
- An A/Wisconsin/67/2022 (H1N1) pdm09-like virus.
- An A/District of Columbia/27/2023 (H3N2)-like virus.
- A B/Austria/1359417/2021 (B/Victoria lineage)-like virus.
VFC program The Vaccines for Children (VFC) program is a federally funded program that provides vaccines at no cost to eligible children who might not otherwise be vaccinated because of inability to pay. Children under age 19 are eligible for the VFC program. Children are eligible if they are any of the following:
- Medicaid eligible.
- Uninsured.
- Underinsured.
- American Indian/Native American.
When using VFC stock, append modifier SL to the vaccine code. Modifier SL indicates VFC stock used and only allows reimbursement for the administration of vaccine.Per Medi-Cal guidelines: “Medi-Cal vaccine injection codes billed for recipients eligible to receive VFC program vaccines will be reimbursed only in documented cases of vaccine shortage, disease epidemic, vaccine delivery problems or instances when the recipient does not meet the special circumstances required for VFC special-order vaccines. A provider’s non-enrollment in the VFC program is not a justified exception.”However, the Alliance will make an exception for non-VFC providers.
How to bill
- Do not bill the CPT code with the SL modifier.
- Document “non-VFC” in box 19 of the CMS claim form or box 80 of the UB-04 claim form.
- Send the claim to CCAH (the Alliance), Attention: Sharlene Gianopoulos.
All claims must be billed on UB-04, CMS-1500 or their electronic equivalent.
| All Alliance lines of business (Effective date September 1, 2025, through June 30, 2026) | |||
| Applies to members linked to your practice, non-linked members (no referral required) or administrative members. | |||
| Vaccine Name | Dosage | Age Group | CPT Code |
| Afluria® (IIV3) | 0.5 mL PFS 10-bx* | 3 Years & Older | 90656 |
| 5 mL MDV.5 mL/dose | 3 Years & Older | 90658 | |
| Fluad® (IIV) | 0.5 mL PFS 10-bx* | 65 years & older | 90653 |
| Fluarix® (IIV3) | 0.5 mL PFS 10-bx* | 3 Years & Older | 90656 |
| Flublok® | 0.5 mL PFS 10-bx* | 18 years & older | 90673 |
| Flucelvax® (ccIIV3) | 0.5 mL PFS 10-bx* | 6 months & older | 90661 |
| 5 mL MDV.25 mL/dose | 6 months & older | 90661 | |
| FluLaval® (IIV3) | 0.5 mL PFS 10-bx* | 6 months & older | 90656 |
| FluMist®(LAIV3) | 0.2 mL spray 10-bx* | 2 to 49 years | 90660 |
| Fluzone® (IIV) | 0.5 mL PFS 10-bx* | 6 months & older | 90656 |
| 5 mL MDV.5 mL/dose | 3 Years & Older | 90658 | |
| Fluzone® High-Dose (IIV) | 0.5 mL PFS 10-bx* | 65 years & older | 90662 |
| Immunization Registries | |
| Vaccine Name | Immunization Service Name with CVX* |
| Afluria® | Influenza, injectable, trivalent, pres free (140) |
| Influenza, injectable, trivalent (141) | |
| Fluad® | Influenza, injectable, subunit, adjuvanted, pres free (168) |
| Fluarix® | Influenza, injectable, trivalent, pres free (140) |
| Flublok® | Influenza, recombinant, trivalent, injectable, pres free (155) |
| Flucelvax® | Influenza, injectable, MDCK, pres free, trivalent (153) |
| Influenza, injectable, MDCK, trivalent (320) | |
| FluLaval® | Influenza, injectable, trivalent, pres free (140) |
| FluMist® | Influenza, live, intranasal, trivalent (111) |
| Fluzone® | Influenza, injectable, split virus, trivalent, pres free (140) |
| Influenza, injectable, split virus, trivalent (141) | |
| Fluzone® High-Dose | Influenza, injectable, high dose split virus, pres free (135) |
*Correct CVX code for immunization registries is needed for Care Based Incentives (CBI).
Patients/parents must not “opt out” of immunization registry sharing for vaccine information to be available. A patient/parent may request to change their sharing status at any time and be updated through the registry’s website.
For more information, please see disclosures on registry websites.
