Alameda Alliance Wellness Pharmacy Exception Process

Exception Process:

You or your provider may submit a Request for Medicare Prescription Drug Coverage Determination to request medications that are not on our Medication Formulary, or are on our Medication Formulary but have a Step Therapy requirement, or another restriction like a Quantity Limit. An exception is very similar to a prior authorization except it occurs when the Alliance does not have a Medication Review Guideline for the medication. You or your provider must use the Request for Medicare Prescription Drug Coverage Determination when submitting a request for review. The request is reviewed based on evidence of medical necessity and on a case-by-case basis. Providers must provide the necessary medical information to support the exceptions. Only a licensed pharmacist or physician from the Alliance can make final decisions on these requests. The medications that require exceptions are subject to change.

Exceptions encourage the appropriate and efficient use of medications by allowing coverage only when certain conditions are met.

The exception process is based upon current medical findings and medication compendia, FDA-approved manufacturer labeling information, and recommendations by the Alliance’s P&T (Pharmacy & Therapeutics) Committee. The Alliance will review your request and make a decision within 24 hours (for urgent requests) or 72 hours (for non-urgent requests) from the time received. 

We are here to help

If you would like to discuss the decision with an Alliance Medical Director, please call:

  • Alliance Pharmacy Services Department
  • Monday – Friday, 8 am – 5 pm
  • Phone Number: 1.510.747.4541

Prescription Management Safety Initiatives 

Opioids are medications used to treat severe pain. Incorrect use can pose serious health risks. The Alliance Wellness, in collaboration with PerformRX (our pharmacy benefit manager), is implementing safety measures to help manage opioid use and ensure member safety.

When you take an opioid prescription to the pharmacy, safety checks may occur to confirm proper use. We may also contact you and your healthcare provider to share helpful information. To avoid delays in receiving your medication, we encourage you to discuss these safety measures with your doctor. 

Summary of New and Expanded Opioid Safety Measures: 

  • Opioid and Benzodiazepine Use: The pharmacy will be notified when filling an opioid or benzodiazepine prescription. 
  • Duplicate Long-Acting Opioid: The pharmacy will be notified when filling multiple long-acting opioids.  
  • Multiple Pharmacies or Providers: Monitoring for prescriptions filled at different locations or by multiple providers. 
  • 7-Day Initial Fill Limit: Members new to opioids will be limited to a 7-day supply on their first fill. 
  • Refill Tolerance: Opioid prescriptions may only refill when 85% of the medication has been used (based on the prescribed day supply).  

Drug Management Program (DMP)

The Alliance Wellness Drug Management Program helps members safely use prescription opioids and other medications that may be frequently misused.

If we determine, in consultation with your healthcare providers, that your use of opioids or benzodiazepines may not be safe, we may place limits on how these medications are obtained. 

Possible limitations may include: 

  • Requiring all prescriptions from a single pharmacy and/or provider 
  • Limiting the quantity of medications covered 
  • Restriction of combination of opioids and benzodiazepines  
  • If limitations are applied, you will receive a letter explaining the restrictions and have the opportunity to indicate your preferred doctor or pharmacy. If you disagree with our assessment, you or your doctor may file an appeal. 

The DMP does not apply if you: 

  • Have cancer or sickle cell disease 
  • Are receiving hospice, palliative, or end-of-life care 
  • Are a resident of a long-term care (LTC) facility 
  • For questions, please contact PerformRx at 1.844.411.0579, 24 hours per day, 7 days a week.