Frequently Asked Questions (FAQs) About Formulary Coverage
- What Is a Formulary?
- Can a Formulary Change?
- What Are Generic Drugs?
- What are Compounded Drugs?
- What Are Over-the-Counter (OTC) Drugs?
- What If My Drug Is Not On The Formulary?
- How Do I Request An Exception To The Granite Alliance Formulary?
- What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
- Who Can I Contact For More Information?
- Can Someone Else Represent Me?
What Is a Formulary?
A formulary is a list of covered drugs selected by Granite Alliance in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Granite Alliance will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.Top
Can a Formulary Change?
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug unless the drug is removed from the market for safety concerns. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by Granite Alliance, please check the Granite Alliance formulary list, or contact us.
In the event of a (non-routine) mid-year formulary change such as moving a preferred formulary drug to a non-preferred formulary tier, adding an additional requirement or limit to a drug, removing a dosage form, or exchanging one drug for therapeutic alternative by adding or deleting a drug or changing a tier as a result of a therapeutic alternative, we will notify you by providing you with a written notice of the (non-routine) formulary change. Please visit our website or refer to your monthly Explanation of Benefits (EOB) for the (non-routine) formulary change. In addition, we will also update our online searchable formulary.Top
What Are Generic Drugs?
Granite Alliance covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.Top
What are Compounded Drugs?
Compounded drugs are composed of two or more ingredients and they require a prescription from a physician. In addition, compounded drugs are prepared by a pharmacist who mixes the various ingredients to customize the drug to meet your individual medical needs. Compounded drugs often have the same active ingredients as generic prescription drugs and brand name drugs, but they are different in (a) strength, (b) inactive ingredients such as preservatives, dyes, sugars and other inactive ingredients found in regular prescription drugs, and (c) form.Top
What Are Over-the-Counter (OTC) Drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Granite Alliance Insurance Company does not cover OTC drugs.Top
What If My Drug Is Not On The Formulary?
If your drug, drug strength or drug’s dosage form (examples of dosage forms include but are not limited to an extended release tablet, suspension, or an injection) is not included in the formulary, you should contact Granite Alliance’s Member Service team to confirm the drug coverage.
If you learn that Granite Alliance does not cover your drug, you have two options:
- You can ask Member Services for a list of similar drugs that are covered by Granite Alliance. When you receive the list, show it to your doctor or other prescriber and ask him or her to prescribe a similar drug that is covered by Granite Alliance. If you prefer you can also take a printed formulary to your next doctor or other prescriber’s appointment to ask if another drug on the formulary list could be used for your condition.
- You can ask Granite Alliance to make an exception and cover your drug. See below for information about how to request an exception.
How Do I Request An Exception To The Granite Alliance Formulary?
You can ask Granite Alliance to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at the Tier 3 – Non-Preferred benefit.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Granite Alliance limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
- You can ask us to provide a different level of coverage for your drug. If your drug is in tier 3 you can ask us to cover it at the cost-sharing amount that applies to drugs in tier 2 or tier 1, as applicable. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Special Drugs tier.
Generally, Granite Alliance will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact Granite Alliance to ask for a coverage determination for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your doctor or other prescriber supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting documentation. You can request an expedited (fast) exception if you or your prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s supporting statement.
For more information on how to request an exception, please refer to our Coverage Determination Process.Top
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a coverage determination from us before you can fill your prescription. You should talk to your doctor or other prescriber to decide if you should switch to a drug that we cover or request a formulary exception so that we will cover the drug you take. We may cover your drug while you talk to your doctor or other prescriber to determine the right course of action for you. Please refer to our Transition Process for additional information.Top
Who Can I Contact For More Information?
For more detailed information about your Granite Alliance prescription drug coverage, please review your Pharmacy Benefit Guide, also known as the Evidence of Coverage, and other plan materials.
If you have questions about Granite Alliance, please call Member Services at:
- Toll Free at 1-855-586-2573 (TTY users call 711). We are available 24 hours a day, 7 days a week.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048, 24 hours a day/7 days a week. Or, visit www.medicare.gov.Top
Can Someone Else Represent Me?
An appointed representative is a relative, friend, advocate, doctor, or other person authorized to act on your behalf in communicating with us regarding coverage determinations, grievances, and appeals. Click here for more information on how to appoint a representative.Top