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 Insurance Company (PDP), at 1-855-586-2573 (TTY users call 711), or visit mygraniterx.com. You may also contact Medicare at 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048, 24 hrs 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).
Note: Fields marked with a single asterisk ( * ) are required.