Grievance process resources, CBI workshop + upcoming PAD changes
Review the grievance process
Providers play a critical role in ensuring the grievance process is thorough and handled with care. To support you in this process, we have a presentation on our Веб-сайт, which covers:
- Understanding member grievances.
- Timeframes and process overview.
- Provider responsibilities.
- Provider expectations and escalation process.
- Grievance response request and provider guidance.
- Provider resources.
If you have questions, please contact a Provider Relations Representative at 800-700-3874, ext. 5504. Thank you for helping us address members’ concerns.
Join us for the 2026 Care-Based Incentive workshop!
Learn about provider incentives at the annual Стимулирование на основе ухода (CBI) workshop that will be presented on Oct. 1. The CBI program consists of incentives which are paid to qualifying contracted provider sites.
In the workshop, we will present:
An overview of the 2026 CBI program.
A description of the 2026 measure changes and new measures.
Information about resources, such as Cultural and Linguistic Services and the Data Submission Tool (DST).
Подробности и регистрация
When: Wednesday, Oct. 1, from noon to 1:30 p.m.
Где: Online via Microsoft Teams.
To register, sign up онлайн or contact a Provider Relations Representative at 800-700-3874, ext. 5504.
Изменения в правилах приема лекарств, назначаемых врачом, вступающие в силу с 1 сентября 2025 г.
The Alliance has made changes to physician administered drug (PAD) benefits. For additional PAD updates effective Sept. 1, please see the Aug. 15 edition of the Дайджест провайдера. You can find prior authorization (PA) criteria on our Веб-сайт.
The changes are as follows:
| Код HCPCS | Лекарство | Изменять | Предпочтительный препарат |
| J0750 | Эмтрицитабин 200 мг и тенофовир дизопроксил фумарат 300 мг (Трувада) | Увеличенный лимит количества | |
| J0751 | Эмтрицитабин 200 мг и тенофовир алафенамид 25 мг (Descovy) | Увеличенный лимит количества | |
| J3299 | Триамцинолона ацетонид (Ксипере) | Новые критерии ПА | Кеналог, Тризенце |
| J7312 | Дексаметазон (Озурдекс) | Update PA criteria | Кеналог, Тризенце |
| J7313 | Флуоцинолона ацетонид (Илувиен) | Update PA criteria | Кеналог, Тризенце |
| J7314 | Флуоцинолона ацетонид (Ютик) | Update PA criteria | Кеналог, Тризенце |
| J7311 | Флуоцинолона ацетонид (Retisert) | Update PA criteria | Кеналог, Тризенце |
| J7351 | Биматопрост (Дуриста) | Новые критерии ПА | Биматопрост, Латанопрост |
| J7355 | Травопрост (iDose TR) | Новые критерии ПА | Биматопрост, Латанопрост |
| J2782 | Avacincaptad Pegol (Izervay) | Новые критерии ПА | |
| J2781 | Пегцетакоплан (Сифовр) | Новые критерии ПА | |
| Q9999 | Ustekinumab-Aauz (Otulfi), Biosimilar, 1 Mg | Новые критерии ПА | adalimumab, etanercept, infliximab |
| J2351 | Ocrelizumab, 1 Mg And Hyaluronidase-Ocsq (Ocrevus Zunovo) | Новые критерии ПА | |
| J3032 | Eptinezumab-jjmr (Vyepti) | Новые критерии ПА | Fremanezumab-vfrm (Ajovy),
Galcanezumab-gnlm (Emgality)
|
| J0585 | OnabotulinumtoxinA (Botox) | Modified PA criteria | Fremanezumab-vfrm (Ajovy),
Galcanezumab-gnlm (Emgality)
|
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).
