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 one (1) business day.
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