Medicare Part D Coverage Determination Request Form

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Granite Alliance Insurance Company (PDP)
P.O. Box 899
Salt Lake City, UT 84110
MEDICARE PART D COVERAGE DETERMINATION REQUEST
Who May Make a Request: You or your prescriber may ask us for a coverage determination. If you want
another individual (such as a family member or friend) to make a request for you, that individual must be your
appointed representative. For more information on appointing a representative contact us, Granite Alliance, at
1-855-586-2573 (TTY users call 711), or visit . You may also contact Medicare at 1-
800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048, 24 hours/7 Days a week.
Representation documentation for requests made by someone other than enrollee or the enrollee’s
prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization
of Representation Form CMS-1696 or a written equivalent).
Complete the following section ONLY if the person
MEMBER INFORMATION
making this request is not the member or the prescriber
Name
Requester’s Name
DOB __ __ / __ __ / __ __
Phone __ __ __ - __ __ __ - __ __ __ __
Requester’s Relationship to Member
MEMBER ID NUMBER
Phone
__ __ __ - __ __ __ - __ __ __ __
Address
Address
City
City
State
Zip
State
Zip
MEDICATION INFORMATION
Medication Name
Strength
Quantity Requested Per Month
Diagnosis
Directions
TYPE OF COVERAGE DETERMINATION REQUEST
I need a drug that is not on the plan’s list of covered medications (formulary exception). *
I have been using a medication that was previously included on the plan’s list of covered medications,
but is being removed or was removed from the list during the plan year (formulary exception). *
I request prior authorization for the medication my prescriber has prescribed. *
I request an exception to the requirement that I try another medication before I get the medication my
prescriber has prescribed (formulary exception). *
I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I
can get the number of pills my prescriber has prescribed (formulary exception). *
Continued on next page
S3875_COV16_109F

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