Central California Alliance For Health


Pharmacy Services

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Pharmacy Formulary

View our formulary by:

• Complete Formulary Guide (PDF)

The Alliance formulary was developed under the direction of the Alliance Pharmacy & Therapeutics (P&T) Committee and is reviewed quarterly by the P&T Committee and Alliance staff. Please note that since benefits vary by line of business, some drugs or classes of drugs are not covered for some members.

Contact Us

If you have any questions, please contact the Alliance Pharmacy department by telephone at (831) 430-5507 Monday through Friday, 8AM-5PM and by fax at (831) 430-5851.

After Business Hours Requests

For assistance outside of the Alliance’s business hours (8AM-5PM, Monday through Friday, excluding holidays), requests for emergency supply, vacation/lost-medication overrides, and co-pay overrides, call the Pharmacy HelpDesk at MedImpact at (800)788-2949. MedImpact may authorize up to a 5 day supply of medication, pending further authorization by the Alliance.

Prior Authorizations

Prior Authorization Criteria:

The Alliance’s Prior Authorization Criteria outline the general criteria by which non-formulary drugs can be prescribed. Exceptions to these criteria are made on a case-by-case basis through the prior authorization process. The Alliance prior authorization criteria is developed by our P&T Committee and is reviewed at least annually.

Use the Alliance Provider Portal to Submit Pharmacy Prior Authorizations

To save paper and increase efficiency, providers may submit pharmacy prior authorizations through the Alliance Provider Portal (Portal). If you have questions, please contact the Provider Services Web & EDI Specialist at (831) 430-5518.

Prior Authorization Form

All Alliance lines of business (Medi-Cal and IHSS) are required to use a standardized Prior Authorization Form to request prior authorizations.>


• Hepatitis C virus (HCV) Checklist: Use this resource for HCV medication requests, ie. Zepatier, Epclusa, etc. (PDF)

• Prior Authorization Information Request for Injectable Drugs: Use this form for chemotherapy, HCPCS J-code requests, and other IV medication request administered by the physician/hospital. (PDF)

• High Dose Opioid Regimen Checklist: Use this form for opioid drugs that exceed our quantity limits. (PDF)

Pharmacy Opioid Policies

Policy 403-1121 – Quantity Limits for Opioid Medications
Policy 403-1139 – Opioid Utilization Review
Policy 403-1140 – Opioid Refill Policy

Synagis Statement of Medical Necessity

These Synagis documents discuss criteria for Synagis and how to obtain prior authorization. For providers who wish to administer Synagis in their office, the Statement of Medical Necessity form is required to be submitted along with the prior authorization request. The Alliance will cover Synagis for members who meet Conditions of Usage listed in Synagis Policy 403-1120.
   – Synagis Statement of Medical Necessity
   – Synagis Policy

Diplomat Specialty Pharmacy

Alliance mandates use of Diplomat Specialty Pharmacy for dispensing all specialty medications. Diplomat can be reached by phone at (877) 977-9118 and by fax at (800) 550-6272.

Epocrates Resources

Epocrates is a free online drug and formulary resource that contains the latest drug and prescribing information. To locate a drug from the Alliance formulary in the Epocrates database, please see the diagram below and follow the steps on the Epocrates website. Epocrates is also available online or to download to mobile devices.


View formulary changes by year:

• 2018

• 2017

• 2016

• 2015

• 2014

• 2013

• 2012

• 2011


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