A. What Is a Prescription Drug Formulary?
B. Generic and Brand Name Drugs
C. Prior Authorization (PA)
D. Exception Requests
E. Transition Policy
F. Drug Search
G. Information on Other Topics:

a. Definitions
b. Our Formulary and Formulary Update Policy
c. Tier Structure
d. Tips for Reducing Out-of-Pocket Drug Costs
e. Prescription Drug Programs
f. Out of Network Coverage
g. Part D Member Rights and Responsibilities
h. Quality Assurance and Medication Therapy Management programs
i. Our Pharmacy Transition Policy and Process

H. Best Available Evidence Policy
I. Forms & Documents

a. Coverage Determination Request Form (for Member use)
b. Coverage Determination Request Form (for Provider use)
c. Appointment of Representative Form
d. Prior Authorization (PA) Guidelines
e. Step Therapy Criteria
f. Transition Policy

A. What Is A Prescription Drug Formulary?
Alliance CompleteCare uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you or you can click here to see our complete formulary below on our Web site.

For information about our Medicare Part D Prescription Drug program, call us toll-free at:



B. Generic and Brand Name Drugs
Alliance CompleteCare covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

C. Prior Authorization (PA)
If you are currently taking a drug that requires a Prior Authorization (PA), you may choose to submit a Coverage Determination Request by sending us a completed Coverage Determination Request Form. Click here for the Coverage Determination Request Form (for Member use). If someone is submitting the Coverage Determination Form on your behalf, they must also submit the Appointment of Representative Form. Click here for the Appointment of Representative Form. Both forms must be complete and require the beneficiary’s signature. You can also submit your Coverage Determination Request on line. Please click here and follow the instruction to submit the request. For a complete list of Prior Authorization (PA) Guidelines, click here. To download our Instructions for Requesting a Prior Authorization, Click here.

D. Exception Requests
If you are currently taking a drug that is not on our formulary, or is subject to step therapy or quantity limits, you can contact us to initiate an Exception Request or you may switch to an alternative drug listed on our formulary with your physician’s help. An Exception Request requires a physician's supporting statement (PSS). A PSS must be submitted for the request process to begin. A PSS is a medical justification to support the need for the requested medication and is written by your physician. In some cases, Alliance CompleteCare 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, Alliance CompleteCare may not cover drug B unless you try Drug A first. If Drug A does not work for you, Alliance CompleteCare will then cover Drug B. Click here to see our Step Therapy Criteria. Click here to download our Instructions for Exception Requests.

E. Transition Policy
For drugs that require prior authorization or exception, you may also be able to get them under our Transition Policy. Click here to see our transition policy.

F. Drug Search
Here are three simple ways to help you determine whether a specific prescription drug is covered by your Alliance CompleteCare health plan. Please select from the options below.

Option 1: Search By Name

Name of Drug

Acidifying and Alkalinizing Agents Adrenals Adrenocortical Insufficiency Alpha-Adrenergic Blocking Agents Ammonia Detoxicants Analgesics and Antipyretics -- Analgesics And Antipyretics, Miscellaneous -- Nonsteroidal Anti-inflammatory Agents -- Opiate Agonists -- Opiate Partial Agonists Androgens Anorexigenics, Respiratory, Cerebral Stimulants -- Amphetamines -- Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous Anthelmintics Anti-infectives (EENT) Anti-infectives (Skin and Mucous Membrane) -- Antibacterials (Skin and Mucous Membrane) -- Antifungals (Skin and Mucous Membrane) -- Antivirals (Skin and Mucous Membrane) -- Local Anti-infectives, Miscellaneous -- Scabicides and Pediculicides Anti-infectives (systemic), Miscellaneous Anti-inflammatory Agents (EENT) Anti-inflammatory Agents (GI Drugs) Anti-inflammatory Agents (Respiratory) Anti-inflammatory Agents (Skin and Mucous) Antiallergic Agents Antibacterials -- Aminoglycosides -- Antibacterials, Miscellaneous -- Cephalosporins -- Macrolides -- Miscellaneous B-lactam Antibiotics -- Penicillins -- Quinolones -- Sulfonamides (Systemic) -- Tetracyclines Anticholinergic Agents -- Antimuscarinics/Antispasmodics Anticonvulsants -- Anticonvulsants, Miscellaneous -- Hydantoins -- Succinimides Antidiabetic Agents -- Antidiabetic Agents, Miscellaneous -- Insulins -- Sulfonylureas -- Thiazolidinediones Antidiarrhea Agents Antiemetics -- 5-ht3 Receptor Antagonists -- Antiemetics, Miscellaneous -- Antihistamines (GI Drugs) Antifungal (Systemic) -- Antifungals, Miscellaneous -- Azoles -- Echinocandins Antiglaucoma Agents Antilipemic Agents -- Antilipemic Agents, Miscellaneous -- Bile Acid Sequestrants -- Fibric Acid Derivatives -- HMG-CoA Reductase Inhibitors Antimigraine Agents -- Selective Serotonin Agonists Antimycobacterials Antineoplastic Agents Antiparkinsonian Agents Antiprotozoal Agents Antipruritics and Local Anesthetics Antiulcer Agents Antivirals (Systemic) -- Antiretrovirals -- Antivirals, Miscellaneous -- Interferons -- Nucleosides and Nucleotides Anxiolytics, Sedatives and Hypnotics -- Anxiolytics, Sedatives and Hypnotics, Miscellaneous Astringents Beta-Adrenergic Blocking Agents Blood Derivatives Calcium-Channel Blocking Agents -- Calcium-Channel Blocking Agents, Miscellaneous -- Dihydropyridines Caloric Agents Cardiac Drugs -- Antiarrhythmic Agents -- Cardiac Drugs, Miscellaneous Cathartics and Laxatives Cell Stimulants and Proliferants Central Nervous System Agents, Miscellaneous Contraceptives Descr41 -- Descr61 Descr42 -- Descr62 Devices Diuretics -- Diuretics, Miscellaneous -- Loop Diuretics -- Potassium-sparing Diuretics -- Thiazide Diuretics EENT Drugs, Miscellaneous Enzymes Estrogens and Antiestrogens First Generation Antihistamines Genitourinary Smooth Muscle Relaxants GI Drugs, Miscellaneous Heavy Metal Antagonists Hematologic Agents -- Anticoagulants -- Hematologic Agents, Miscellaneous -- Platelet-aggregation Inhibitors Hematopoietic Agents Hypotensive Agents -- Hypotensive Agents, Miscellaneous Ion-Removing Agents Irrigating Solutions Keratolytic Agents Keratoplastic Agents Local Anesthetics Miscellaneous Therapeutic Agents Myasthenia Gravis Mydriatics Opiate Antagonists Parasympathomimetics (Cholinergic Agents) Parathyroid Pituitary Progestins Psychotherapeutic Agents -- Antidepressants -- Antipsychotic Agents Renin-Angiotensin-Aldosterone System Inhibitors -- Angiotensin II Receptor Antagonists -- Angiotensin-Converting Enzyme Inhibitors Replacement Preparations Respiratory Tract Agents, Miscellaneous Sclerosing Agents Second Generation Antihistamines Serums Skeletal Muscle Relaxants Skin and Mucous Membrane Agents, Miscellaneous Somatotropin Agonists and Antagonists Sympatholytic Adrenergic Blocking Agents -- Alpha-Adrenergic Blocking Agents Sympathomimetic (Adrenergic) Agents Thyroid and Antithyroid Agents Toxoids Urinary Anti-infectives Vaccines Vasodilating Agents Vitamins and Minerals

Drug Class

Option 2: Search Alphabetically

Simply click on the letter below to find a complete listing of all medications in the Alliance CompleteCare Drug Formulary beginning with that letter.

ABCDEFGHIJKLMNOPQRSTUVWXYZ

OPTION 3: SEARCH THE PRINTABLE FORMULARY

Formulary Drugs 2012 in English / Español / 中文(List of Covered Drugs) – updated monthly

*If your drug is in Tier 1, only the generic drug is covered.
*If your drug is in Tier 2, the brand-name drug is covered.
*If your drug is in Tier 3, it is a specialty drug

A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

G. Information on Other Topics
Click here for more information on these topics:

a. Definitions
b. Our Formulary and Formulary Update Policy
c. Tier Structure
d. Tips for Reducing Out-of-Pocket Drug Costs
e. Prescription Drug Programs
f. Out of Network Coverage
g. Part D Member Rights and Responsibilities
h. Quality Assurance and Medication Therapy Management programs
i. Our Pharmacy Transition Policy and Process

H. Best Available Evidence Policy
Best Available Evidence Policy

I. Forms & Documents

a. Coverage Determination Request Form (for Member use)
b. Coverage Determination Request Form (for Provider use)
c. Appointment of Representative Form
d. Prior Authorization (PA) Guidelines
e. Step Therapy Criteria; Instructions for Exception Requests
f. Transition Policy

Formulary, drug search, and utilization management information last updated February 2012.