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 website, 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 Care-Based Incentive (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).
Mga detalye at pagpaparehistro
When: Wednesday, Oct. 1, from noon to 1:30 p.m.
saan: Online via Microsoft Teams.
To register, sign up online or contact a Provider Relations Representative at 800-700-3874, ext. 5504.
Mga pagbabago sa gamot na pinangangasiwaan ng doktor upang malaman, epektibo sa Set. 1, 2025
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 Provider Digest. You can find prior authorization (PA) criteria on our website.
The changes are as follows:
| HCPCS Code | Gamot | Baguhin | Ginustong Gamot |
| J0750 | Emtricitabine 200Mg At Tenofovir Disoproxil Fumarate 300Mg (Truvada) | Tumaas na limitasyon sa dami | |
| J0751 | Emtricitabine 200Mg At Tenofovir Alafenamide 25Mg (Descovy) | Tumaas na limitasyon sa dami | |
| J3299 | Triamcinolone Acetonide (Xipere) | Bagong pamantayan ng PA | 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) | Bagong pamantayan ng PA | Bimatoprost, Latanoprost |
| J7355 | Travoprost (iDose TR) | Bagong pamantayan ng PA | Bimatoprost, Latanoprost |
| J2782 | Avacincaptad Pegol (Izervay) | Bagong pamantayan ng PA | |
| J2781 | Pegcetacoplan (Syfovre) | Bagong pamantayan ng PA | |
| Q9999 | Ustekinumab-Aauz (Otulfi), Biosimilar, 1 Mg | Bagong pamantayan ng PA | adalimumab, etanercept, infliximab |
| J2351 | Ocrelizumab, 1 Mg And Hyaluronidase-Ocsq (Ocrevus Zunovo) | Bagong pamantayan ng PA | |
| J3032 | Eptinezumab-jjmr (Vyepti) | Bagong pamantayan ng PA | 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).
