Granite Alliance has many resources available for our members to help provide information and detail about their plan benefits. Any of the forms listed below can be faxed or mailed to us. If you can’t find the information you’re looking for please contact Granite Alliance directly and we’ll be happy to further assist you.
If you have any questions about your pharmacy benefits, you are always welcome to contact Granite Alliance directly. You can also reference your Summary of Benefits, Evidence of Coverage, Pharmacy Directory, or Formulary below. The Evidence of Coverage will provide you with the most detailed information about your prescription coverage, including what is and what is not covered, how to get your prescriptions filled, what you will pay for your prescriptions, and what to do if you are unhappy about something related to your prescriptions.
2023 Plan Benefit Information
2023 Evidence of Coverage: This document is going to provide you with the most comprehensive information about your plan. It will help you identify your plan benefits, what you will pay for your medications throughout the year, and give you details about how you can contact us for assistance.
2023 Summary of Benefits: This document provides a high-level summary of plan benefits and features, including premium and copay/coinsurance amounts.
2023 Pharmacy Directory: This contains a listing of most of the pharmacies that are contracted within your network. Granite Alliance does offer nationwide coverage throughout the United States, so we recommend using our Pharmacy Locator tool to search for additional pharmacies.
2023 Formulary (Drug List): This is a comprehensive listing of all the covered medications under your plan, along with their associated Tier levels so you can determine what copay you might pay. We also recommend using our Drug Pricing Tool to help you with determining your costs.
2023 Star Ratings: Every year, Medicare evaluates plans based on a 5-star rating system. The Centers for Medicare & Medicaid Services (CMS) considers how well the plans perform in different categories, including customer service, patient safety, and member experience and satisfaction. Granite Alliance is proud to be a 3.5 star rated plan!
Coverage Determination Form: Use this form to request coverage of a drug that is not listed on your formulary, or to make an exception to your coverage requirements.
Redetermination Form: If we deny your request for coverage, you can ask us to review and reevaluate our decision.
Direct Member Reimbursement Form: This form can be used if you have paid the full cost of your medication out of pocket and would like to ask for reimbursement.
Foreign Reimbursement Form: This form can be used if you are a DMBA member traveling internationally and recieve a medication that you would like to have reimbursed.
Mail Order Form: If you would like to order Home Delivery services through Magellan Rx Pharmacy please use this form.
Appointment of Representative Form: This is used to appoint a representative to act on your behalf. They can then file a Grievance, Coverage Determination, or an Appeal. Your representative may be a relative, friend, advocate, doctor, or anyone else you feel would best represent you.
Personal Medication List: This is a helpful form to help you keep track of your medications. If you are eligible for our Medication Therapy Management program they will also ask you to complete this form.
Multi-Language Assistance: Do you speak another language? We'd be happy to help you get a translator on the line.
Non-Discrimination Notice: Granite Alliance does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex/gender.
1 (855) 586-2573,
TTY Users call 711
Granite Alliance Insurance Company
PO Box 1382
Maryland Heights, MO 63043
We are available 24 hours a day, 7 days a week
1 (888) 656-8099
Last Updated Date: 1/10/2023
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