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

Generic Substitutions

The Alliance has a mandatory generic medication program. This program promotes the use of generic over brand-name options, when medically appropriate. When your doctor writes you a prescription for a brand-name medication, your doctor must submit a Prescription Drug Prior Authorization (PA) Request to the Alliance. The Alliance will review the request and will inform the doctor of the decision within request within 24 (for urgent requests) to 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 Prescription Drug Prior Authorization (PA) Request to the Alliance. The Alliance will review the request and will inform the doctor of the decision within request within 24 (for urgent requests) to 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 medication, the Alliance has a limit on the number of pills we will cover. In general, a 30-day supply is covered. If you require a medication that exceeds the limit, your doctor can submit a Prescription Drug Prior Authorization (PA) Request to the Alliance. The Alliance will review the request and will inform the doctor of the decision with request within 24 (for urgent requests) to 72 hours (for non-urgent requests) from the time received.

Prior Authorization (PA) Process

Your doctor may submit a Prescription Drug Prior Authorization (PA) Request 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 with request within 24 (for urgent requests) to 72 hours (for non-urgent requests) from the time received.

Exception Process

Your doctor may submit a Prescription Drug Prior Authorization (PA) Request to request 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 with request within 24 (for urgent requests) to 72 hours (for non-urgent requests) from the time received.

You have the right to request an external review when the Alliance denies a prior authorization (PA) request for a drug that is not covered by the plan or for an investigational drug or therapy. A request for an external review will not prevent you from filing a grievance or Independent Medical Review (IMR) with the California Department of Managed Health Care (DMHC).

Each outpatient prescription request will be reviewed via a PA exception request within 24 (for urgent requests) to 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 (for urgent requests) to 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 medication 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.

Please Note: Types of tiers on the Alliance formulary include Tier 1 (generic medications) and Tier 2 (brand medications). Tier 1 medications have a $10 copayment for a 30-day supply and Tier 2 medications have a $15 copayment for a 30-day supply. The Alliance has a mandatory generic medication program that promotes the use of generic over brand-name options.

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

The Alliance provides coverage of standard fertility preservation services when a covered treatment may directly or indirectly cause iatrogenic infertility and are not within the scope of coverage for treatment infertility.

The Alliance provides formulary prescription coverage for antiretroviral medications including pre-exposure prophylaxis (PrEP) without prior authorization/step therapy requirement.

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

• Alliance Member Services Department
• Monday – Friday, 8 am – 5 pm
• Phone Number: 1.510.747.4567
• Toll-Free: 1.877.932.2738
• People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

In compliance with state rules, the Alliance will cover a three-day supply of medication for you in emergency situations. This policy applies to medication that normally would require a Prescription Drug Prior Authorization (PA) Request or exceptions request.

Emergency situations include:

• A recent discharge from an emergency room (ER).
• A recent discharge from the hospital.
• Any event that involves an imminent and serious threat, including (but not limited to) severe pain, potential loss of life, limb, or major bodily function.

Contracted Alliance pharmacies can help you obtain an emergency supply. You can find a list of pharmacies that work with us in the Alliance Provider Directory or online Pharmacy Search.

After the three-day supply is over, your provider will need to submit a Prescription Drug Prior Authorization (PA) Request. The Alliance will review the request and will inform the doctor of the decision with request within 24 (for urgent requests) to 72 hours (for non-urgent requests) from the time received.

Some medications require special care. For example, the medication may need to be refrigerated, given as a shot or taken with special instructions.

PerformSpecialty Pharmacy handles these medications for the Alliance:

PerformSpecialty Pharmacy Drug List

To learn more, please contact:

PerformSpecialty Pharmacy
Toll-Free: 1.855.287.7888
www.performspecialty.com/ 

90-Day Supply on Maintenance Medications

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. 

There are some procedures and limits that 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 has a mandatory generic program. This program 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) or72 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. 

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 medication 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, including holidays
Toll-Free: 1.888.88A.DSNP (1.888.882.3767)
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929 

Some medications require special care. For example, the medication may need to be refrigerated, given as a shot or taken with special instructions.

PerformSpecialty Pharmacy handles these medications for the Alliance:

PerformSpecialty Pharmacy Drug List

To learn more, please contact:

PerformSpecialty Pharmacy
Toll-Free: 1.855.287.7888
www.performspecialty.com/ 

90-Day Supply on Maintenance Medications