Granite Alliance uses a formulary to identify covered medications. The
formulary is a list of drugs covered by Granite Alliance. Granite Alliance
covers both brand-name drugs and generic drugs. Generic drugs have the same
active ingredient as a brand name drug and are considered by the Food and Drug
Administration (FDA) to be as safe and effective as brand name drugs.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Important Message About What You Pay for Insulin - You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on, even if you haven't paid your deductible.
Please refer to our Transition Process for information on a process that will help you transition to medications that are covered on Granite Alliance’s formulary or request an exception.
Granite Alliance has several tools that are available to help you search for covered medications. You can use our online Granite Alliance formulary search tool or download a comprehensive formulary listing. A comprehensive formulary is the complete list of drugs covered by a prescription drug plan.
The Granite Alliance formulary is reviewed on a regular basis by physicians and pharmacists to evaluate new medications and therapies. This review may result in changes to the formulary. Beneficiaries who are taking an impacted medication will be notified in advance of the change. Click below to view recent changes to the formulary.
If you want a Comprehensive Formulary mailed to you, or if you need help finding a medication, please call 855-586-2573 (TTY: 711). You may also email your request for a formulary at GAICHelp@primetherapeutics.com. Please visit our contact us page for additional information.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and help us control drug plan costs so we can pass on savings to members. A team of doctors and pharmacists developed these requirements and limits to help us to provide quality care to our members.
You can find out if your drug is subject to these additional requirements or limits by looking in our formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. For more information on how to request an exception, please refer to our Coverage Determination Process. Listed below are some of the restrictions you may find.
Granite Alliance requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Granite Alliance before you fill your prescriptions. If you don’t get approval, Granite Alliance may not cover the drug. Covered drugs that require prior authorizations are indicated in the formulary. You can also review a document listing our Prior Authorization Criteria.
In some cases, Granite Alliance 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, Granite Alliance may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Granite Alliance will then cover Drug B. Covered drugs that require step therapy are indicated in the formulary. A list of these drugs and their criteria can be found in our Step Therapy Criteria document.
A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. Covered drugs that have quantity limits are indicated in the formulary.
Certain drugs may be covered under either Medicare Part B or Part D. Information needs to be submitted to Granite Alliance in order for us to determine the correct coverage. Covered drugs that require a Part B versus a Part D determination are indicated in the formulary.
When there is a generic version of a brand name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand name drug. You can ask Granite Alliance to make an exception to these restrictions or limits.
Certain drugs are excluded from coverage by Medicare, and so your Granite Alliance plan is also unable to cover these medications. The following include the drugs that are excluded
A formulary is a list of covered drugs selected by Granite Alliance in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Granite Alliance will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug unless the drug is removed from the market for safety concerns. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by Granite Alliance, please check the Granite Alliance formulary list, or contact us.
In the event of a (non-routine) mid-year formulary change such as moving a preferred formulary drug to a non-preferred formulary tier, adding an additional requirement or limit to a drug, removing a dosage form, or exchanging one drug for therapeutic alternative by adding or deleting a drug or changing a tier as a result of a therapeutic alternative, we will notify you by providing you with a written notice of the (non-routine) formulary change. Please visit our website or refer to your monthly Explanation of Benefits (EOB) for the (non-routine) formulary change. In addition, we will also update our online searchable formulary.
Granite Alliance covers both brand name drugs and generic drugs. 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.
Compounded drugs are composed of two or more ingredients and they require a prescription from a physician. In addition, compounded drugs are prepared by a pharmacist who mixes the various ingredients to customize the drug to meet your individual medical needs. Compounded drugs often have the same active ingredients as generic prescription drugs and brand name drugs, but they are different in (a) strength, (b) inactive ingredients such as preservatives, dyes, sugars and other inactive ingredients found in regular prescription drugs, and (c) form.
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Granite Alliance Insurance Company does not cover OTC drugs.
If your drug, drug strength or drug’s dosage form (examples of dosage forms include but are not limited to an extended release tablet, suspension, or an injection) is not included in the formulary, you should contact Granite Alliance’s Member Service team to confirm the drug coverage.
If you learn that Granite Alliance does not cover your drug, you have two options:
You can ask Granite Alliance to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
Generally, Granite Alliance will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact Granite Alliance to ask for a coverage determination for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your doctor or other prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting documentation. You can request an expedited (fast) exception if you or your prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s supporting statement.
For more information on how to request an exception, please refer to our Coverage Determination Process.
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a coverage determination from us before you can fill your prescription. You should talk to your doctor or other prescriber to decide if you should switch to a drug that we cover or request a formulary exception so that we will cover the drug you take. We may cover your drug while you talk to your doctor or other prescriber to determine the right course of action for you. Please refer to our Transition Process for additional information.
Last Updated Date:11/18/2023
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