Central California Alliance For Health


Pharmacy Services

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Pharmacy Formulary

The Alliance formulary was developed under the direction of the Alliance Pharmacy & Therapeutics (P&T) Committee and is reviewed quarterly by the P&T Committee and Alliance staff. Please note that since benefits vary by line of business, some drugs or classes of drugs are not covered for some members.

Click here to view our Complete Formulary Guide (PDF).

Contact the Pharmacy Department

Please contact the Alliance Pharmacy department at:
Phone: (831) 430-5507    Fax at (831) 430-5851
Monday through Friday, 8AM-5PM

After Business Hours Requests

For assistance outside of the Alliance’s business hours, please contact:

MedImpact (800)788-2949
MedImpact reviews request for emergency supply, vacation/lost medication overrides and co-pay overrides. They may authorize up to a 5 day supply of medication, pending further authorization by The Alliance.

Prior Authorizations

To submit a prior authorization:

1. Fax.
    Click here for the PA form.

2. Submit via the Alliance Provider Portal.
    If you don’t have a Portal account, please click here to request an account or
    contact the Provider Services Portal Support Specialist at (831) 430-5518.

Prior Authorization Criteria:

The Alliance’s Prior Authorization Criteria outlines the general criteria by which non-formulary drugs can be prescribed. Exceptions to these criteria are made on a case-by-case basis through the prior authorization process. The Alliance prior authorization criteria is developed by our P&T Committee and is reviewed at least annually.

Click here to view our Prior Authorization Criteria (PDF).


In some cases forms specific to a therapeutic class or drug, should be included in addition to the Prior Authorization Request. Submitting this additional information will make the review process quicker and more efficient for the Pharmacy department.

• Hepatitis C virus (HCV) Checklist: Use this resource for HCV medication
  requests, i.e. Mavret, Epclusa, etc. (PDF)

• Prior Authorization Information Request for Injectable Drugs: Use this form
  for chemotherapy, HCPCS J-code requests, and other IV medication request
  administered by the physician/hospital. (PDF)

• High Dose Opioid Regimen Checklist: Use this form for opioid drugs that exceed
  our quantity limits. (PDF)

• Anti-Obesity Agents Form: Submit this form for any non-formulary anti-obesity
  agent medication. (PDF)

• Synagis Statement of Medical Necessity: Use this form along with the Prior
  Authorization Request if Synagis is to be administered in the hospital/provider
  office. The Alliance will cover Synagis for members who meet Conditions of Usage
  listed in the Synagis Policy 403-1120 – Synagis, available in Section 16 of the
  Alliance Provider Manual.

Pharmacy Home Program

The Alliance Pharmacy Home Program (PHP) promotes safe medication use and prevents harm resulting from intentional or unintentional misuse. This program helps reduce potential and actual prescription drug fraud and/or abuse by requiring a member to utilize one pharmacy to fill their PCP-selected drug class. If you would like to enroll an Alliance member into the PHP program, please call the Alliance Pharmacy department at (831) 430-5507.


Pharmacy Opioid Policies

Policy 403-1121 – Quantity Limits for Opioid Medications
Policy 403-1139 – Opioid Utilization Review
Policy 403-1140 – Opioid Refill Policy

Diplomat Specialty Pharmacy

Alliance mandates use of Diplomat Specialty Pharmacy for dispensing all specialty medications. Diplomat can be reached by phone at (877) 977-9118 and by fax at (800) 550-6272.

Epocrates Resources

Epocrates is a free online drug and formulary resource that contains the latest drug and prescribing information. To locate a drug from the Alliance formulary in the Epocrates database, please see the diagram below and follow the steps on the Epocrates website. Epocrates is also available online or to download to mobile devices.


View formulary changes by year:

• 2018

• 2017

• 2016

• 2015

• 2014

• 2013

• 2012

• 2011


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