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Restrictions and Limitations

Are There Any Restrictions On My Coverage?

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.

You can find out if your drug has any additional requirements or limits by looking to the right of each drug in the Granite Alliance formulary list.

Examples of utilization management tools are described below.

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Prior Authorization

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. A list of these drugs and their criteria can also be found by using the link below.

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Quantity Limits

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.

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Step Therapy

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 also be found by using the link below.

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Part B or Part D

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.

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Generic Substitution

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. See the section, “How do I request an exception to the Granite Alliance formulary?” for information about how to request an exception.

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Drugs Not Covered by your Medicare Part D Prescription Drug Plan

The following is a list of drugs excluded by Medicare

  • Drugs used for the treatment of anorexia, weight loss or weight gain
  • Drugs used to promote fertility
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used for symptomatic relief of coughs and colds
  • Vitamins and minerals (except for prenatal vitamins and fluoride preparations)
  • Non-prescription drugs (except insulin and supplies associated with the injection of insulin)
  • Methadone when used for the treatment of opioid dependence
  • Erectile Dysfunction (ED) drugs, unless used to treat a condition, other than sexual dysfunction or erectile dysfunction will meet the definition of a Part D drug when prescribed for medically accepted indications approved by the FDA.

Other Excluded Items

  • Blood glucose testing strips (these are covered under Medicare Part B)
  • Lancets (these are covered under Medicare Part B)
  • Heparin/saline flushes (these are covered under Medicare Part B)
  • Drugs that are not approved by the U.S. Food and Drug Administration (FDA)
  • Drugs that are purchased outside of the United States and its territories
  • Off-label use, in many cases, where a drug is used in any way other than those indicated on a drug's label as approved by the Food and Drug Administration

Coverage Determination and Appeals

You have the right to request a coverage determination if the medication you are taking is not covered by the Granite Alliance formulary or has a utilization management restriction (requires prior authorization, step therapy, quantity limitation, etc.). You also have the right to request a change to the benefit tier that your medication is on. These requests are submitted through a coverage determination request. You need to call or write Granite Alliance to request a coverage determination. You can use the form below to request a coverage determination.

If you have had a coverage determination denied you can appeal the decision. This is also known as a redetermination. You can use the form below to request a redetermination.

For more information please refer to our Coverage Determinations or Appeals Policy.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

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Website content was last updated on 1/20/2021.

Granite Alliance Insurance Company is a Medicare-approved Prescription Drug Plan. Enrollment in Granite Alliance depends on contract renewal.

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