Alliance Health is committed to working with providers to improve members’ health and well-being by delivering physical, behavioral, emotional and social services while respecting the treatment choices of our members. The following information will help your patients get the most out of their pharmacy benefits.
As a Medicaid Tailored Plan in North Carolina, Alliance Health provides pharmacy benefits to our members according to the NC Medicaid Preferred Drug List (PDL) and associated NC Medicaid Outpatient Pharmacy Clinical Coverage Policies. The PDL does not contain a complete list of drugs. Instead, it lists the preferred drugs within the most commonly prescribed therapeutic categories.
Pharmacy Prior Authorizations
Prior authorization is required for certain drugs prescribed to Alliance Health Plan members. Navitus, our contracted Pharmacy Benefit Manager, reviews pharmacy prior authorizations to make sure prescribed medications are safe and appropriate.
Reasons that a medication may require preauthorization:
- Medication is not preferred and other alternatives are recommended
- Dose is outside FDA recommendations
- Medication is a high risk for abuse or misuse
- Medication requires additional information.
See Prior Approval Drugs and Criteria for details.
How to Submit an Outpatient Pharmacy Prior Authorization (PA) Request
Prescribers have three options:
- Log into the Provider Portal and submit a request electronically
- Fax completed Prior Authorization Forms to 855-668-8553
- Call the Pharmacy and Provider Services Line at 855-759-9300 between the hours of 7 a.m. and 6 p.m. EST, Monday through Saturday
Alliance Member and Recipient Services is also available to respond to member questions and concerns about pharmacy benefits at (800) 510-9132 Monday through Saturday, 7 a.m. to 6 p.m. EST.
If a member needs to begin therapy with a medication before the prior authorization request is approved, pharmacies are authorized to dispense up to a 72-hour emergency supply.
If a state of emergency or disaster is declared by the NC Governor, FEMA or the US President, the Alliance Health Pharmacy Benefit Manager will enact the following protocol at the direction of the NC Department of Health and Human Services (NCDHHS) to ensure you can get life-saving medications:
- Alliance will waive prior approval and other coverage requirements for certain non-preferred medications and members will be able to refill medications earlier than is normally allowed. This early refill exception applies to all medications. Member copayment requirements will not be waived during an emergency or disaster.
- Alliance will allow members to obtain up to a 90-day supply of most medications if requested and available a the time of refill.