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Granite Alliance Plan Documents and Forms

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.

Granite Alliance Benefit Documents

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. 

2024 Plan Benefit Information
2024 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.  

2024 Summary of Benefits: This document provides a high-level summary of plan benefits and features, including premium and copay/coinsurance amounts.

2024 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.

2024 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.

Important Granite Alliance Forms

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. 

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.

Other Helpful Granite Alliance Documents

Privacy Policy:  This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.  

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. 
Call Us

1 (855) 586-2573,
TTY Users call 711


Granite Alliance Insurance Company
PO Box 64810
St. Paul, MN 55164


We are available 24 hours a day, 7 days a week


1 (888) 656-8099

Last Updated Date: ​03/21/2024

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