Coverage Determination Form
Use this form to request coverage of a Part D drug.
- Online Coverage Determination Form
- Printable Coverage Determination Form
- Fax Coverage Determination Form - 888-656-8099
Use this form only if you have been denied a coverage determination and would like the Plan to reevaluate the decision.
Direct Member Reimbursement Form
Please print and submit this form if you have paid full price for a covered prescription drug and are asking to be reimbursed by Granite Alliance.
- Printable Direct Member Reimbursement Form
- Fax Direct Member Reimbursement Form - 888-656-8099
Foreign Reimbursement Form
Please print and submit this form if you have paid full price for a medication you received while out of the country and are asking to be reimbursed by your Employer. This is not considered a Part D Benefit.
- Printable Foreign Reimbursement Form
- Fax Foreign Reimbursement Form - 888-656-8099
Appointment of Representative Form
Please print and submit this form to appoint a representative. This representative can file a Grievance, Coverage Determination, or an Appeal on your behalf. Your representative may be a relative, friend, advocate, doctor, or anyone else you feel would best represent you.
Representative Authorization Form
Please print and submit this form to authorize a representative. This representative may obtain your personal health information and have access to all of your records. Your representative may be a relative, friend, advocate, or anyone else you request.
- Granite Alliance Protected Health Information (PHI) Release Authorization Form (prescription drugs)
- Fax Representative Authorization Form - 888-656-8099
Blank Medication Form
This form is for your personal records to help you keep track of what medications you are taking, why you are taking them, when you stopped taking it, and why you stopped (if applicable).
Mail Order Form
Use this order form to enroll in mail order through Magellan Rx Pharmacy and to obtain additional information regarding this service.