Description of Formulary Limits

There are some procedures and limits, explained below, that may apply to the drugs in our formulary.

Generic substitutions: The Alliance has a mandatory generic program. This program promotes the use of generic options over brand when medically appropriate. When your doctor writes you a prescription for a brand name drug and not a generic due to medical need, your doctor must submit a Prior Authorization Form to the Alliance. The Alliance reviews these requests and will inform the doctor of the decision within 1 business day.

Step Therapy: In some cases, the Alliance requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your doctor can request an exception by submitting a Prior Authorization Form to us. The Alliance reviews these requests and will inform the doctor of the decision within 1 business day.

Quantity Limits: For certain drugs, the Alliance has a limit on the number of pills we will cover. In general, a 30-day supply is covered. However, if you require a drug that exceeds the limit, your doctor can submit a Prior Authorization Form to us. The Alliance reviews these requests and will inform the doctor of the decision with 1 business day.

Prior Authorization Process: Your doctor may submit a Prior Authorization Form to request drugs that are not on our Drug Formulary or are on our Drug Formulary but have restrictions.  Restrictions may occur when the quantity of medication prescribed is more than the plan allows or if a medication has Step Therapy Requirements. Medication Review Guidelines (also known as criteria) have been developed for these medications and will be referenced upon receipt of your doctor's request. The Alliance reviews these requests and asks for more information if needed. We will inform the doctor of the decision within 1 business day.

Exception Process: Your doctor may submit a Prior Authorization Form to request drugs that are not on our Drug Formulary or are on our Drug Formulary but have restrictions. This request is called an exception request when the Alliance does not have a Medication Review Guideline (also known as criteria) for the medication. The exception request is reviewed on a case-by-case basis and for evidence of medical necessity. The Alliance reviews these requests and asks for more information if needed. We will inform the doctor of the decision within 1 business day. If you are an Alliance Group Care member, you can make an exception request on-line by logging into the member portal or by calling Member Services at 510 747-4567.

Emergency Supply: To learn more about the Alliance's policy on filling prescriptions in emergency situations, please see Emergency Medication Supply.