Important plan information

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Granite Alliance

P.O. Box 899

SLC, UT 84110

MEMBER INFORMATION

Granite Alliance Insurance Company (PDP)

P.O. Box 899

Salt Lake City, UT 84110

www.mygraniterx.com

MEDICARE PART D REQUEST FOR REDETERMINATION

OF MEDICARE PRESCRIPTION DRUG DENIAL

Because we, Granite Alliance, denied your request for coverage of (or payment for) a prescription drug, you have

the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice

of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Who May Make a Request: You or your prescriber may ask us for a redetermination (appeal). 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 www.mygraniterx.com. You may also contact Medicare at 1-800-

MEDICARE (1-800-633-4227), TTY users 1-877-486-2048, 24 hours a day/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).

MEMBER INFORMATION

Complete the following section ONLY if the person

making this request is not the member or the prescriber

Name

DOB / /

Phone - -

MEMBER ID NUMBER

Address

City

State Zip

Requester’s Name

Requester’s Relationship to Member

Phone - -

Address

City

State Zip

PRESCRIBER’S INFORMATION

Name Contact Person

Address

City State Zip

Office Phone - - Fax - -

For Prescribers requesting a Standard Redetermination: Is the beneficiary aware you are making this request

on their behalf? ☐ Yes ☐ No If “Yes”, Prescriber please initial here:

S3875_RED17_309F Continued on next page

MEDICATION YOU ARE REQUESTING

Medication Name Strength Quantity

Have you purchased the medication pending appeal? ☐ Yes ☐ No

If “Yes”:

Date Purchased Amount Paid $ (attach copy of receipt)

Name of Pharmacy Pharmacy Phone Number

ADDITIONAL INFORMATION

Please explain your reasons for appealing. Attach any additional information you believe may help your

case, such as a statement from your prescriber and relevant medical records. You may want to refer to the

explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

IMPORTANT NOTICE: EXPEDITED DECISIONS

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your

health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your

prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you

a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we

will decide if your case requires fast decision. You cannot request an expedited appeal if you are asking

us to pay you back for a medication you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS (if you have a supporting statement from your prescriber, attach it to this request).

Signature: Date:

Requests may be submitted by:

Mail: Fax: Verbally:

Granite Alliance 888-656-8104 Toll-Free 1-855-586-2573

P.O. Box 899 (TTY users call 711)

Salt Lake City, UT 84110

We are available 24 hours a day, seven days a week.

Our preferred hours are Monday through Friday 7 a.m. to 7 p.m., Mountain Time.

Granite Alliance Insurance Company is a Medicare-approved Prescription Drug Plan.

Authorization responses are faxed to the number listed on the form which should adhere to security

standards for Personal Health Information. For quickest response, please ensure all requested information

is included and complete

Last updated on

August 17, 2017

S3875_MISC17_NONDIS

Nondiscrimination Notice

Granite Alliance Insurance Company (PDP) complies with applicable Federal civil rights laws

and does not discriminate, exclude people or treat them differently on the basis of race, color,

national origin, age, disability, or sex/gender.

Granite Alliance:

Provides free aids and services to people with disabilities to communicate effectively

with us, such as:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic

format and other formats as requested and reasonably available)

Provides free language services to people whose primary language is not English,

Including:

o Qualified interpreters

o Information written in other languages

If you need these services, contact Granite Alliance.

If you believe that Granite Alliance has failed to provide these services or discriminated in

another way on the basis of race, color, national origin, age, disability, or sex, you can file a

grievance in person, by phone, mail, fax, or email.

Mail: Joseph McKee, Sr Director

Pharmacy & Medicare Compliance

11013 W. Broad Street, Suite 500

Glen Allen, VA 23060

Fax: 1-888-656-8097

Email: compliance@mygraniterx.com

Phone: 1-866-435-4854

If you need help filing a grievance, Granite Alliance’s customer service team is available to help

you. They can be reached at 1-855-586-2573 (TTY 711). Granite Alliance’s customer service

team is available 24 hours a day, seven days a week. Preferred hours are Monday through Friday

7 a.m. to 7 p.m., Mountain Time.

You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint

Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.

Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH

Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Granite Alliance Insurance Company (PDP)

P.O. Box 899

Salt Lake City, UT 84110

www.mygraniterx.com

S3875_ENR17_8001L

Multi-Language Assistance Services

English: If you speak English, language assistance services, free of charge, are available to you.

Call 1-855-586-2573 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al 1-855-586-2753 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-586-

2573（TTY：711）。

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành

cho bạn. Gọi số 1-855-586-2573 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수

있습니다. 1-855-586-2573 (TTY: 711)번으로 전화해 주십시오.

Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee

1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-855-586-2573 (TTY: 711).

Nepali: ध्यान दिनुहोस्: तपारं्इले नेपाली बोल्नुहुन्छ भने तपारं्इको दनम्ति भाषा सहायता सेवाहरू दनिःशुल्क

रूपमा उपलब्ध छ । फोन गनुुहोस् 1-855-586-2573 (दिदिवार्इ: 711) ।

Tongan: FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea

‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-855-586-2573

(TTY: 711).

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga

serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-586-2573 (TTY: 711).

Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći

dostupne su vam besplatno. Nazovite 1-855-586-2573 (TTY- Telefon za osobe sa oštećenim

govorom ili sluhom: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-586-2573 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные

услуги перевода. Звоните 1-855-586-2573 (телетайп: 711).

S3875_ENR17_8001L

Arabic:

)رقم 2573-586-855-1اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم ملحوظة: إذا كنت تتحدث

(.711 هاتف الصم والبكم:

Mon-Khmer, Cambodian: ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា

បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-855-586-2573 (TTY: 711)។

French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont

proposés gratuitement. Appelez le 1-855-586-2573 (ATS : 711).

Japanese:

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-586-

2573（TTY:711）まで、お電話にてご連絡ください。