Medicare Part D Coverage Determination Request Form (Page 2 of 3) in pdf

TYPE OF COVERAGE DETERMINATION REQUEST (continued)

My drug plan charges a higher copayment for the medication my prescriber has prescribed than it

charges for another medication that treats my condition, and I want to pay the lower copayment (tiering

exception). *

I have been using a medication that was previously included on a lower copayment tier, but is being

moved to or was moved to a higher copayment tier (tiering exception). *

My drug plan charged me a higher copayment for a medication than it should have.

I want to be reimbursed for a covered medication that I paid for out of pocket.

*Note: If you are asking for a formulary or tiering exception, your prescriber MUST provide a

statement supporting your request. Requests that are subject to prior authorization (or any other

utilization management requirement), may require supporting information. Your prescriber may

use the attached “Supporting Information for an Exception Request or Prior Authorization” to

support your request.

ADDITIONAL INFORMATION WE SHOULD CONSIDER (attach any supporting documents)

IMPORTANT NOTE: EXPEDITED DECISIONS

If you or your prescriber believe that waiting 72 hours 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 72 hours could seriously harm your health, we will automatically give you

a decision within 24 hours. If you do not obtain your prescriber’s support for an expedited request, we will

decide if your case requires a fast decision. You cannot request an expedited coverage determination 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 24 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

801-503-3880

801-503-3850 or

P.O. Box 899

Toll-Free 1-855-586-2573

Salt Lake City, UT 84110

(TTY users call 711)

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.

Continued on next page

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.

Medicare Part D Coverage Determination Request Form Page 2