Medication Request Form

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January 10, 2014
IMPORTANT ANNOUNCEMENT
Please read carefully and
keep this letter for your records
Beginning January 1, 2014, Alameda Alliance for Health (Alliance) contracted with a new
Pharmacy Benefit Manager, PerformRx, to process pharmacy claims and prior authorizations.
This announcement provides new prior authorization submission information.
New Prior Authorization Phone and Fax Numbers Starting January 1, 2014
Program
New PerformRx Call Center
New Prior Authorization Fax
Alliance CompleteCare (HMO SNP)
1-855-251-0966
Standard: 1-855-811-9327
Hours: 24/7
Urgent: 1-855-851-4054
(Medicare Part D Program)
1-855-508-1713
Medi-Cal
Standard and Urgent:
Hours: 8:30-5:30 PST
1-855-811-9329
Alliance Group Care (IHSS)
Mon-Fri
New Prior Authorization Forms
New Prior Authorization Forms are attached and located on our website in a convenient, fillable
PDF format:
Providers
Pharmacy and Drug Benefits
2014 Medi-Cal/Group Care Prior Authorization Form or
2014 Alliance CompleteCare Medicare Coverage Determination Request Form
New Online Prior Authorization Submission URLs
Submit a prior authorization request online through PerformRx’s web submission form located
in the Alliance Provider Portal:
Providers
Log In
New 2014 Prior Authorization
Forms
Select appropriate link for each line of business
Not yet registered? Register under Provider Log-In to create your user account.
New Phone and Fax Number for Diplomat Specialty Pharmacy
Specialty injectable medications will continue to be dispensed through Diplomat Pharmacy
Phone: 1-855-347-4783, Fax: 1-855-399-3248
Need assistance? Speak to an Alliance Provider Service Representative at (510) 747-4510.

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