Central California Alliance For Health

 

Pharmacy Services

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Pharmacy Formulary

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.


Click here to view our Complete Formulary Guide (PDF).


Contact the Pharmacy Department

Please contact the Alliance Pharmacy department at:
Phone: (831) 430-5507    Fax at (831) 430-5851
Monday through Friday, 8AM-5PM


After Business Hours Requests

For assistance outside of the Alliance’s business hours, please contact:

MedImpact (800)788-2949
MedImpact reviews request for emergency supply, vacation/lost medication overrides and co-pay overrides. They may authorize up to a 5 day supply of medication, pending further authorization by The Alliance.


Prior Authorizations

To submit a prior authorization:


1. Fax.
    Click here for the PA form.


2. Submit via the Alliance Provider Portal.
    If you don’t have a Portal account, please click here to request an account or
    contact the Provider Services Portal Support Specialist at (831) 430-5518.


Prior Authorization Criteria:

The Alliance’s Prior Authorization Criteria outlines 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.


Click here to view our Prior Authorization Criteria (PDF).


Nutritional Supplements

The Alliance covers oral nutritional supplements and enteral formulas for Medi-Cal eligible members when medically necessary.


A prior authorization will need to be submitted via the Alliance Portal or by fax to the Alliance Pharmacy Department at (831)430-5851.

Please include the following when submitting a Prior Authorization:

•  Copy of prescribing provider’s prescription

•  Completed Prior Authorization request form

•  Recent chart notes that address medical justification as to why the member is unable to meet his/her nutritional needs with standard or fortified foods

•  Growth charts for pediatric members or relevant weight history for adult members


Conditions that may necessitate oral nutritional supplements or enteral formulas include, but are not limited to:

•  Increased metabolic needs

•  Cow’s milk allergy/intolerance to standard formulas in infancy

•  Preterm birth

•  Cancer with significant weight loss

•  Decubitus ulcers

•  ESRD on HD or PD

•  Severe swallowing or chewing difficulty

•  Conditions impairing digestion and absorption

•  Failure to Thrive

•  Underweight status or unintended weight loss defined by the Medi-Cal guidelines.


The Alliance will not authorize oral nutrition supplements when used for convenience or preference of the member or provider.


All requests will be reviewed for medical necessity by the Alliance’s Registered Dietitians (RDs).


For a list of covered products, please see the Medi-Cal Enteral Formulary, available here.


The Alliance’s Enteral Nutrition policy can be accessed here.


For additional information regarding the criteria for authorization, please contact the Alliance RDs Tony Nannini, RD at (831) 430-4117 or Christine Lally, RD at (831) 430-2519.


Forms

In some cases forms specific to a therapeutic class or drug, should be included in addition to the Prior Authorization Request. Submitting this additional information will make the review process quicker and more efficient for the Pharmacy department.


• Hepatitis C virus (HCV) Checklist: Use this resource for HCV medication
  requests, i.e. Mavret, 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)


• Anti-Obesity Agents Form: Submit this form for any non-formulary anti-obesity
  agent medication. (PDF)


• Synagis Statement of Medical Necessity: Use this form along with the Prior
  Authorization Request if Synagis is to be administered in the hospital/provider
  office. The Alliance will cover Synagis for members who meet Conditions of Usage
  listed in the Synagis Policy 403-1120 – Synagis, available in Section 16 of the
  Alliance Provider Manual.


Pharmacy Home Program

The Alliance Pharmacy Home Program (PHP) promotes safe medication use and prevents harm resulting from intentional or unintentional misuse. This program helps reduce potential and actual prescription drug fraud and/or abuse by requiring a member to utilize one pharmacy to fill their PCP-selected drug class. If you would like to enroll an Alliance member into the PHP program, please call the Alliance Pharmacy department at (831) 430-5507.


Resources

Provider Portal Tips

Use this resource for instructions on checking pharmacy prior authorization status on the Alliance Provider Portal. (PDF)


Pharmacy Opioid Policies

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



View formulary changes by year:

• 2018

• 2017

• 2016

• 2015

• 2014

• 2013

• 2012

• 2011


 

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