Medicare Part D Coverage Determination Request Form Page 3

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Supporting Information for an Exception Request or Prior Authorization
FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber’s
supporting statement. PRIOR AUTHORIZATION requests may require supporting information.
REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify
that applying the 72 hour standard review timeframe may seriously jeopardize the life or
health of the enrollee or the enrollee’s ability to regain maximum function.
Prescriber’s Information
Name
Address
City
State
Zip
Office Phone
Fax
Prescriber’s Signature
Date
Diagnosis and Medical Information
Medication
Strength and Route of Administration
Frequency
New Prescription OR Date Therapy Initiated
Expected Length of Therapy
Quantity
Height
Weight
Drug Allergies
Diagnosis
Rational for Request
Alternate medication(s) contraindicated or previously tried, but with adverse outcome, e.g.,
toxicity, allergy, or therapeutic failure [Specify below: (1) Medication(s) contraindicated or tried;
(2) adverse outcome for each; (3) if therapeutic failure, length of therapy on medication(s)]
Patient is stable on current medication(s); high risk of significant adverse clinical outcome
with medication change [Specify below: Anticipated significant adverse clinical outcome]
Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage
form(s) and/or dosage(s) tried; (2) explain medical reason]
Request for formulary tier exception [Specify below: (1) Formulary or preferred medications
contraindicated or tried and failed, or tried and not as effective as requested medication; (2) if
therapeutic failure, length of therapy on each medication and adverse outcome; (3) if not as
effective, length of therapy on each medication and outcome]
Other (explain below)
Required Explanation
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.

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