Quality Assurance

Drug Management Utilization Reviews

We conduct drug utilization reviews for all of our members to make sure that you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Possible medication errors
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies
• Drug dosage errors

In addition to reviews while you are filling a prescription - we do retrospective reviews by periodically examining our claims data and other records. If we identify a pattern of inappropriate or medically unnecessary care we will work with your doctor to help correct the problem. Part of our daily review also ensures that all claims are paying appropriately and our members are being billed accurately for their copayments. If a claim happened to be rejected we also review that to ensure that it did reject appropriately. If we have any concerns we will reach out to either you directly, or your pharmacy, to help resolve any potential discrepancies. We do everything we can to make sure you are receiving your medications as needed. 

Quality Improvement Initiatives

Granite Alliance consistently strives to identify and work towards areas of improvement. We collect feedback from members through inquiries into our call center, grievances filed by members, we conduct surveys, and we hold Focus Groups. Based on feedback we have received we have worked to make improvements in some of the following areas:

• Star Rating Improvements
• Improvement in Clinical Programs
• Technological Advancements in Data Analytics
• Implementation of proactive texting programs
• Electronic resources including paperless document availability

This is not an all-encompassing list and we continuously have projects underway to further improve our plan and the benefits we can offer. If you have feedback or suggestions about your plan we encourage you to contact us directly. 

Our efforts for Quality Improvement have been nationally recognized and in 2021 we received the PQA Laura Cranston Quality Improvement Award for demonstrating significant improvement in PQA measures of medication safety and appropriate use. The Quality Improvement Award recognizes plans that received a 5-star rating on the 2021 CMS Quality Improvement measure and the greatest combined improvement in star ratings from 2020 to 2021 on the five PQA medication measures used in the CMS program during this period. More information about this award can be found

Star Rating Program

The Centers for Medicare & Medicaid Services (CMS) creates plan ratings that indicate the quality of Medicare plans on a scale of 1 to 5 stars with 5 stars being the highest rating. Every year, Medicare evaluates plans based on a 5-star rating system. The overall star rating is determined through numerous performance measures across several domains of performance. Each measure is awarded a star rating and the individual measure stars are then aggregated at the domain and summary level. Only a small number of plans receive a 5-star summary rating from CMS, with most plans receiving 3 to 4 stars. Granite Alliance did not receive a Star Rating for 2024.

The Star Ratings evaluate dozens of measures across the plan, however there is a heavy focus on the following areas:

Pharmacy Benefit Management

Granite Alliance partners with our Pharmacy Benefit Management provider, Prime Therapeutics. They help us manage your prescription drug benefits. Prime Therapeutics strives to provide the same care they would want for their loved ones, by delivering holistic care and deep knowledge to uncover savings and improve health. Through the various solutions that Prime offers they have earned many accreditations from both URAC and NCQA which we are proud to share!