Formulary Management Process

Providers can view and search through our formulary using the links below. This formulary applies to Medi-Cal and Alliance Group Care.

Drug Formulary

The drug formulary includes a list of drugs covered by the Alliance to meet your patient’s needs. The Alliance regularly updates its  Drug Formulary. You can access the Alliance's Medi-Cal Drug Formularies by clicking here.

Formulary Updates

The Alliance’s Pharmacy & Therapeutics Committee (P&T Committee) meets quarterly to review the drug formulary, drug utilization patterns, and to establish and/or update the formulary, guidelines, protocols, programs, and procedures that help ensure high quality, cost-effective drug therapy.

Formulary Updates 07-2017 - Reflects updates for July 2017

Formulary Updates 04-2017 - Reflects updates for April 2017

Formulary Updates 01-2017 - Reflects updates for January 2017

Formulary Updates 09-2016 - Reflects updates for October 2016

Formulary Updates 06-2016 - Reflects updates for July 2016

Formulary Updates 03-2016 - Reflects updates for April 2016

Formulary Updates 12-2015 - Reflects updates for January 2016

Formulary Updates 9-2015 - Reflects updates for October 2015

Formulary Updates 5-2015 - Reflects updates for July 2015

Formulary Updates 3-2015 - Reflects updates for May 2015

Formulary Updates 12-2014 - Reflects updates for February 2015

Formulary Updates 9-2014 - Reflects updates for November 2014

Formulary Updates 6-2014 – Reflects updates for August 2014

Formulary Updates 3-2014 – Reflects updates for April 2014

Formulary Updates 12-2013 – Reflects updates for February 2014

Archives of Past Formulary Updates

Past formulary updates appear below.

Formulary Updates 9-2013 Reflects updates for September 2013

Formulary Updates 6-2013 Reflects updates for June 2013

Formulary Updates 3-2013 Reflects updates for March 2013

Formulary Updates 12-2012 – Reflects updates for December 2012 

Formulary Updates 9-2012 – Reflects updates for September 2012

Formulary Updates 6-2012 – Reflects updates for June 2012 

Formulary Updates 3-2012 – Reflects updates for March 2012

Formulary Updates 12-2011 – Reflects updates for December 2011

Formulary Updates 9-2011 – Reflects updates for September 2011

Formulary Updates 6-2011 – Update for June 2011

Formulary Updates 3-2011 – Update for March 2011

Formulary Updates 12-2010 – Update for December 2010

Providers can submit a completed Formulary Review Request Form to the P&T Committee for their consideration for review of a drug.

Formulary Management Procedures

Certain restrictions and limits may apply to the drugs on the Alliance’s Drug Formulary.

Generic Substitution

The Alliance has a mandatory generic program. The intent of this program is to promote utilization of appropriate generic alternatives as first line therapies when medically appropriate.

If a brand name product is necessary in lieu of an approved generic due to documented medical need, a written Prior Authorization Form must be submitted. Procedures and timeframes will follow our Prior Authorization process.

Therapeutic Interchange

The Alliance may use Therapeutic Interchange to promote rational pharmaceutical therapy when evidence suggests that outcomes can be improved by substituting a drug that is therapeutically equivalent but chemically different from the prescribed drug.

Therapeutic Interchange protocols are never automatic; a dispensing provider may not substitute a therapeutically equivalent alternative drug for the prescribed drug without the knowledge and authorization of the prescribing practitioner.

Step Therapy

The Alliance uses Step Therapy to promote cost-effective pharmaceutical management when there are multiple effective drugs to treat a medical condition.

Drugs that have a step therapy requirement will require one or more “prerequisite” first step drugs to be tried before progressing to the second step drug. When a prescription for a Step Therapy drug is filled at the dispensing pharmacy, the pharmacy benefits claims processor will search past claims for the first step drugs.

A Step Therapy drug can be obtained without first trying a first step drug by submitting a Prior Authorization Form with documentation of existing medical need for consideration. Procedures and timeframes will follow our Prior Authorization process.

Quantity Limits

A quantity limit establishes the maximum amount of medication that the Alliance will cover within a defined period of time.

If a member has a medical condition that requires a quantity of medication that exceeds our limit, a written Prior Authorization Form, along with documentation of existing medical need, must be submitted for consideration. Procedures and timeframes will follow our Prior Authorization process.

Age & Gender Limits

When there is a clear justification for certain age or gender groups, the Alliance will apply Age or Gender Limits. For example, Prenatal vitamins are limited to females only.

If a medication is required outside of the age or gender limit, a written Prior Authorization Form, along with documentation of existing medical need, must be submitted for consideration. Procedures and timeframes will follow our Prior Authorization process.

Machine Readable Formulary

MACHINE READABLE FORMULARY FILE 

In accordance with 42 CFR 438.10(i)(1) - (3), The Alliance has made available a machine readable formulary file in the format specified by the Secretary of Health and Human Services. This file includes which drugs are covered (brand and generic name) and the tier of the medication.


For Pharmacy Questions

Contact the Alliance Provider Services department at 510-747-4510, Monday-Friday, 7:30 am - 5:30 pm.