Exception Process:

Prescribers may submit a Prescription Drug Prior Authorization (PA) Request to request medications that are not on our Medication Formulary, or are on our Medication Formulary but have a Step Therapy requirement, or have a Quantity Limit. An exception is very similar to a prior authorization except occurs when the Alliance does not have a Medication Review Guideline for the medication. Prescribers must use the Prescription Drug PA Request 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 (for urgent requests) to 72 hours (for non-urgent requests) from the time received.

A request for an external review when the Alliance denies a prior authorization (PA) can be made 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 the filing of a grievance or Independent Medical Review (IMR) with the California Department of Managed Health Care (DMHC). Requests for external review will be made and completed in the Alliance Grievances and Appeals Department.

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