March 14, 2014
IMPORTANT ANNOUNCEMENT
Please read carefully and
keep this letter for your records
March 14, 2014
Dear Provider,
We understand there has been some confusion in our pharmacy network
regarding how to process medication claims for Alliance Medi-Cal members who
transitioned from HealthPAC MCE, a Low Income Health Program (LIHP), on
1/1/2014.
To ease the transition, we have provided the attached documents to our
Alameda County pharmacy network to help them:
 Fill temporary 3-day medication supplies
Use of a temporary 3-day supply will promote continuity of care for
members whose medications now require a prior authorization.
Providers should submit a prior authorization as soon as possible. The prior
authorization process takes 5 days for standard requests and 72 hours for
urgent requests. The new prior authorization forms are attached. Please
note the new fax numbers.
 Identify Medi-Cal Carve-Out Drugs covered by the State
Information regarding processing claims for Medi-Cal Carve-Out drugs will
help reduce the number of prior authorization requests you receive for
these medications (antipsychotics, AIDS drugs, and addiction treatment
drugs).
We encourage providers to fax this information to any pharmacy that
continues to send prior authorization requests for a Medi-Cal Carve-Out
drug.
Sincerely,
Pharmacy Services
March 14, 2014
IMPORTANT ANNOUNCEMENT
Please read carefully and
keep this letter for your records
Temporary 3-Day Supply of Medications
The Alliance allows pharmacies to dispense a one-time 3-day supply of medication
to allow time for a prior authorization to be submitted.
To fill a temporary 3-day supply:
 Submit a claim for only a 3-day supply
 If necessary, enter authorization code 632333
Please ensure the prescriber is contacted to submit a prior authorization. The
prior authorization process takes 5 days for standard requests and 72 hours for
urgent requests.
Note: Prior authorization requests that do not contain enough information to
establish continuity of care may be pended while addition information is
requested from the prescriber.
Medi-Cal Carve-Out Drugs
The Alliance is actively working to increase transparency regarding Medi-Cal
Carve-Out drug reject messaging. The POS messaging will be updated to help
improve your workflow.
Please see the following pages for Medi-Cal Carve-Out Drugs Frequently Asked
Questions.
For more help, call:
 Alliance Pharmacy Services at 510-747-4541, Mon-Fri, 9 a.m. - 5 p.m. (PST)
 PerformRx at 1-855-508-1713, Mon-Fri, 8:30 a.m. - 5:30 p.m. (PST)
March 14, 2014
IMPORTANT ANNOUNCEMENT
Please read carefully and
keep this letter for your records
Medi-Cal Carve-Out Drugs
Frequently Asked Questions
1. What is a carve-out drug?
The Alliance carves out certain drugs to the Department of HealthCare Services (DHCS). These
drugs are covered by the Medi-Cal Fee-for-Service (FFS) program and are billed to the State by
the pharmacy. Please note that all other drugs remain the responsibility of the Alliance.
2. What drugs are carved out?
The following 3 classes are carved out (see attached list for specific drugs):



Antipsychotic drugs
AIDs drugs
Alcohol, Heroin Detoxification and Dependency Treatment drugs
3. How do I bill Medi-Cal FFS for the carve-out drugs?
Using member information on the member’s BIG card, submit the claim as you would for all
other Medi-Cal FFS member using BIN 610442 and PCN 147CAPA.
4. I am having problems billing Medi-Cal FFS; who do I contact for help?
Please contact the Medi-Cal Pharmacy Help Desk at 1-800-572-9315
Additionally, you can visit the DHCS website for a list of pharmacy FAQs and answers:
http://files.medi-cal.ca.gov/pubsdoco/ncpdp/ncpdp_faq.asp#L6
The Alliance and our pharmacy benefit manager, PerformRx, cannot assist with resolving claim
issues since the claim is not billed to us. If you do call us we can only direct you to the above
help desk.
5. I am getting non-covered reject for the carve-out drug; to whom should I submit a prior
authorization?
Please submit a Treatment Authorization Request (TAR) to Medi-Cal FFS. The Alliance does not
review prior authorizations for the carve-out drugs and will issue an administrative denial for
such requests.
Alliance Carve-Out Drugs
The drugs listed below are carved-out to Medi-Cal FFS. Pharmacies
should bill Medi-Cal FFS using the appropriate BIN and PCN. If a drug
within any of the three categories is not listed below, obtain coverage
by submitting a Treatment Authorization Request (TAR) form to MediCal FFS.
AIDS Drugs
Selected HIV AIDS treatment drugs that meet DHCS, Medi-Cal
Managed Care Division definitions are carved-out:
Abacavir/Lamivudine
Abacavir Sulfate
Amprenavir
Atazanavir Sulfate
Darunavir Ethanolate
Delavirdine Mesylate
Dolutegravir (Tivicay)
Efavirenz
Efavirenz/Emtricitabine/
Tenofovir Disoproxil Fumarate
Elvitegravir/Cobicistat/
Emtricitabine/Tenofovir
Disoproxil Fumarate (Stribild)
Emtricitabine
Emtricitabine/Rilpivirine/
Tenofovir Disoproxil Fumarate
Emtricitabine/Tenofovir
Enfuvirtide
Etravirine
Alcohol and Heroin
Detoxification and
Dependency Treatment
Drugs
Fosamprenavir Calcium
Indinavir Sulfate
Lamivudine
Lopinavir/Ritonavir
Maraviroc
Nelfinavir Mesylate
Nevirapine
Raltegravir Potassium
Rilpivirine Hydrochloride
Ritonavir
Saquinavir
Saquinavir Mesylate
Stavudine
Tenofovir Disoproxil Fumarate
Tipranavir
Zidovudine/Lamivudine
Zidovudine/Lamivudine/
Abacavir
Sulfate
Selected alcohol and heroin detoxification and dependency treatment
drugs that meet DHCS, Medi-Cal Managed Care Division definitions
are carved-out:
Acamprosate Calcium
Buprenorphine HCl
Buprenorphine/Naloxone HCl
Buprenorphine Transdermal Patch *
Naloxone HCl
Naltrexone (oral and injectable)
Naltrexone Microsphere Injectable Suspension
* Not all forms of this drug are FDA approved for the treatment of
alcohol and heroin detoxification and dependency. The drug
remains carved out of capitation regardless of the diagnosis for
which it was used.
October 2013
Alliance Carve-Out Drugs
Psychiatric Drugs
Carved-out psychiatric drugs are as follows:
Amantadine HCl
Aripiprazole
Asenapine (Saphris)
Benztropine Mesylate
Biperiden HCl
Biperiden Lactate
Chlorpromazine HCl
Chlorprothixene
Clozapine
Fluphenazine Decanoate
Fluphenazine Enanthate
Fluphenazine HCl
Haloperidol
Haloperidol Decanoate
Haloperidol Lactate
Iloperidone (Fanapt)
Isocarboxazid
Lithium Carbonate
Lithium Citrate
Loxapine HCl
Loxapine Succinate
Lurasidone Hydrochloride
Mesoridazine Mesylate
Molindone HCl
Olanzapine
Olanzapine Fluoxetine HCl
Olanzapine Pamoate Monohydrate
(Zyprexa Relprevv)
Paliperidone (Invega)
Paliperidone Palmitate
(Invega Sustenna)
Perphenazine
Phenelzine Sulfate
Pimozide
Proclyclidine HCl
Promazine HCl
Quetiapine
Risperidone
Risperidone Microspheres
Selegiline (transdermal only)
Thioridazine HCl
Thiothixene
Thiothixene HCl
Tranylcypromine Sulfate
Trifluoperazine HCl
Triflupromazine HCl
Trihexyphenidyl
Ziprasidone
Ziprasidone Mesylate
October 2013
200 Stevens Drive
Attention: Prior Authorization
Philadelphia, PA 19113
Phone: (855) 251-0966
Standard Fax: (855) 811-9327
Urgent Fax: (855) 851-4054
Medicare Part D Coverage Determination Request Form
This form cannot be used to request:
Medicare non-covered drugs, including fertility drugs, drugs prescribed for weight loss, weight gain or hair growth,
over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
Plan Name:
Patient Information
Prescriber Information
Patient Name:
Prescriber Name:
Member ID#
Address:
DEA#
Address:
City:
State
City:
Home Phone:
Zip:
Office Phone#
Sex (circle):
M
F
DOB:
State:
Office Fax:
Zip:
Contact Person:
Diagnosis and Medical Information
Medication:
Strength and Route of Administration
Frequency:
New Prescription OR Date
Expected Length of Therapy:
Qty:
Therapy Initiated:
Height/Weight:
Drug Allergies:
Diagnosis:
Prescriber’s Signature:
Date:
Rationale for Exception Request or Prior Authorization
FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION
Alternate drug(s) contraindicated or previously tried, but with adverse outcome (i.e., toxicity, allergy, or therapeutic failure)
Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of
therapy on each drug(s);
Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on
current drug(s); high risk of significant adverse clinical outcome with medication change
Specify below: Anticipated significant adverse clinical outcome
Medical need for different dosage form and/or higher dosage
Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason
Request for formulary tier exception
Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as
requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective,
length of therapy on each drug and outcome
Other:________________________________________________________________
Explain below
REQUIRED EXPLANATION: ____________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Request for Expedited Review
REQUEST FOR EXPEDITED REVIEW [24 HOURS]
BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR
STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S
ABILITY TO REGAIN MAXIMUM FUNCTION
Information on this form is protected Health Information and subject to all privacy and security regulations under
HIPAA
I
Medicare Part D Coverage Determination Request Form
Revised 10-23-2013
Alameda Alliance for Health
Medication Request Form
Attn: Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
Phone (Medi-Cal/Group Care): 1-855-508-1713
Phone (AllianceSELECT): 1-855-508-1717
Fax: 1-855-811-9329
Instructions:
This form is to be used by participating providers to obtain coverage for a formulary drug with PA guideline, other restrictions, or a nonformulary drug for which there is no suitable alternative available. Please complete this form and fax it to PerformRx at 1-855-811-9329
or call with this information. If you have any questions regarding this process, please contact PerformRx’s Provider Service Line at 1855-508-1713 for Medi-Cal/Group Care and 1-855-508-1717 for AllianceSELECT.
□
Urgent Request (Must be reserved for requests that, in the provider’s best professional judgment, are potentially
life threatening or pose a significant risk to the continuous care of the patient.)
Patient Name
Patient DOB
Patient ID Number
Prescriber Name
Specialty
Prescriber Phone
Prescriber Fax
NPI#
Prescriber Address
Pharmacy Name
Pharmacy Phone
Pharmacy Fax
Medication Name and Strength Requested:
□ Brand Medically Necessary request (Rationale required below)
Directions:
Quantity Requested:
Anticipated Length of Therapy:
□
Days
□ 3 Months
□ 6 Months
□ 12 Months
Diagnosis:
Preferred Medications tried/previous therapy, please include strength, frequency and duration:
Rationale and/or additional information, which may be relevant to the review of this prior authorization
request:
Prescriber Signature
Date
Please Fax Completed Form to 1-855-811-9329
Alameda Alliance for Health Medication Request Form
Revised 12-23-2013