Medicare Pharmacy Resources

The Alliance Pharmacy & Therapeutics (P&T) Committee meets quarterly to review the Alliance Medication Formulary. The P&T Committee reviews medication utilization patterns and creates and updates the formulary, guidelines, protocols, programs, and procedures that help ensure safe and high-quality medication therapy.

To view Alliance Medication Formulary updates, please click here.

• September 2026
• August 2026
• July 2026
• June 2026
• May 2026
• April 2026
• March 2026
• February 2026

Alameda Alliance Wellness Archive

There are some procedures and limits may apply to the medication in our formulary.

Generic Substitutions

A generic drug works the same as a brand-name drug, but usually costs less. The Alliance promotes the use of generic options over brand-name options, when medically appropriate. If a generic drug is available and when your doctor writes you a prescription for a brand-name medication, your doctor must submit a Request for Medicare Prescription Drug Coverage Determination to the Alliance. The Alliance will review the request and will inform the doctor of the decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received.

Step Therapy

In some cases, the Alliance may require you to try a certain medication before we will cover a different medication. Your doctor can request an exception by submitting a Request for Medicare Prescription Drug Coverage Determination to the Alliance. The Alliance will review the request and will inform the doctor of the decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received.

Partial Fill

The Alliance has the availability of prescription partial fills of approved medically necessary medications.

Quantity Limits

For certain medications, the Alliance has a limit on the number of pills we will cover. We might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. In general, a 30-day supply is covered. If you require a medication that exceeds the limit, your doctor may submit a Request for Medicare Prescription Drug Coverage Determination to the Alliance. The Alliance will review the request and will inform the doctor of the decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received.

Prior Authorization (PA) Process

For certain drugs, you or your doctor need to get approval from us before we will agree to cover the drug for you. This is called “prior authorization.” You or your provider may submit a Request for Medicare Prescription Drug Coverage Determination to request a medication that is not on the Alliance Medication Formulary or has restrictions. Restrictions may occur when the quantity of medication prescribed is more than the plan allows or if a medication has Step Therapy Requirements. A Medication Review Guideline (also known as criteria) has been developed for these medications and will be referenced upon receipt of your doctor’s request. The Alliance will review the request and will inform the doctor of the decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received.

Part B vs. Part D Determinations
A drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Exception Process

You or your provider may submit a Request for Medicare Prescription Drug Coverage Determination to ask for a medication that is not on the Alliance Medication Formulary or has restrictions. This request is called an exception request when the Alliance does not have a Medication Review Guideline (also known as criteria) for the medication. The exception request is reviewed on a case-by-case basis and for evidence of medical necessity. The Alliance will review the request and will inform the doctor of the decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received.

Each outpatient prescription request will be reviewed via a PA exception request within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received. Coverage determination documents will be sent to the enrollee (or their designee) and the enrollee’s prescribing provider within this time based on urgent or non-urgent status. Coverage determination documents will include information on appeal rights, procedures, and duration of coverage. If the plan fails to respond to a completed prior authorization exception request within 24 hours (for urgent requests) or 72 hours (for non-urgent requests), then the request will be approved.

Therapeutic Interchange

With your doctor’s approval, the Alliance may change the medication that your doctor originally prescribed to one that is on our formulary that is similar in effectiveness and safety.

Medication Tier

A group of prescription medications that corresponds to a specified cost-sharing tier in the health plan’s prescription medication coverage. The tier in which a prescription medication is placed determines the enrollee’s portion of the cost.

Out-of-Pocket Cost

Copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan.

The Alliance provides copayments that will not be higher than the in-network pharmacy’s retail price for a prescription drug.

If you are an Alameda Alliance Wellness member, you can make an exception request online through the Alliance Member Portal or call:

Alameda Alliance Wellness Member Services Department
Seven (7) days a week, 8 am – 8 pm
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
If you cannot hear or speak well, use TTY or call 1.800.735.2929 

If you are a new member taking a drug not on the formulary (list of covered drugs), you will need to follow the medication transition process. See this section to learn your options.

Read our Transition Policy click here.

The Medication Therapy Management (MTM) program is a free service offered to eligible Medicare Part D members. The program is designed to help members with complex health needs get the most benefit from their medications.

Explore the Medication Therapy Management (MTM) Program

We offer a real-time benefit comparison (RTBC) tool, so enrollees can obtain information about lower-cost alternative therapies under their prescription drug benefit plan. Enrollees can compare cost sharing to find the most cost-effective prescription drugs for their health needs. For example, if a doctor recommends a specific cholesterol-lowering drug, the enrollee could look up what the co-pay would be and see if a different, similarly effective option might save the enrollee money. With this tool, enrollees will be better able to know what they will need to pay before they are standing at the pharmacy counter. For more information about RTBC, please see below:

For more information about RTBC, please log in to the member portal.

The Medicare Prescription Payment Plan^‡ is an optional program that can help Medicare members manage their out-of-pocket costs. The program allows members to spread the cost of a prescription drug throughout the year. Instead of paying the pharmacy, members who enroll will get a bill from our plan to pay for prescription drugs.

If you would like to enroll in the Medicare Prescription Payment Plan, you can download the enrollment form below to print and mail to us. You can also call Member Services to enroll by phone at 1.888.88A.DSNP (1.888.882.3767). TTY users can call 1.800.735.2929. We are open seven (7) days a week, 8 am – 8 pm.

Medicare Prescription Payment Plan Form
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Save on your Medicare Part D drug costs with Extra Help

People with limited income and resources may qualify for the Extra Help program to help pay for their Part D premiums, deductibles, and copayments. If eligible, Medicare could help pay for your drug costs. Also, those who qualify will not be subject to the coverage gap or a late-enrollment penalty.

If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, the amount of extra help you get will determine your total monthly plan premium as a member of our plan.

Download the chart below to see what your monthly plan premium will be if you get extra help.
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If you have questions about sending us information about your Extra Help, please refer to the Best Available Evidence (BAE) website.

^‡ The Medicare Prescription Payment Plan program option, Extra Help from Medicare, and Best Available Evidence (BAE) policy apply to the 2026 plan year.

Stay up to date on medication recalls and safety notices that may affect you. Check here for the latest information and any actions you may need to take.

Medication Recalls and Notices

Medication adherence refers to how consistently a Medicare member takes their prescribed medications as directed by their doctor. Maintaining good adherence ensures medications are effective and prevents health complications. At Alliance Wellness, we partner with you and your providers by sending telephonic proactive refill reminders and helping you overcome any barriers to accessing your medication. Additionally, we are happy to mail you best-practice guides to help you confidently maintain your treatment plan.

• Medicare Request for Drug Coverage Determination (Rx) Form:
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• 2027: Medicare Request for Drug Coverage Determination (Rx) Form
• Medicare Prescription Payment Plan Form (Rx)
• Request for Reimbursement Form (Rx):
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