Pharmacy Exception Process

Exception Process: Prescribers may submit a Prior Authorization Form to request drugs that are not on our Drug Formulary, or are on our Drug Formulary but exceed plan Quantity Limits or have Step Therapy Requirements. 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 this  PA form 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 drug 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 1 business day.
  • If you would like to discuss the decision with an Alliance medical director, please call the Alliance Pharmacy Services Unit at 510-747-4541.

 

Pharmacy Benefit Manager (PBM)

The Alliance partners with PerformRx, a Pharmacy Benefit Manager (PBM). Exception requests will be routed to the Alliance from PerformRx. Providers can contact PerformRx 8:00 am to 5:30 pm, Monday through Friday at 1-855-508-1713 if you need help with Prior Authorizations (PA), Exceptions, Drug Formulary, and Pharmacy Network.