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Managing your prescription benefits

Coverage, appeals, transition policy and MTM

Covered drugs

To see if your drugs are covered, sign in to the member portal and we'll preselect your plan to make your search easier. Or visit the Geisinger Gold formularies section to view without logging in.

Prescription exceptions, determinations and appeals

Don't see your drug in the formulary? Contact Gold Customer Care Team at 800-498-9731 (TTY: 711) to check coverage.

  • Oct. 1 – March 31, daily, 8 a.m. – 8 p.m. ET
  • April 1 – Sept. 30, Monday – Friday, 8 a.m. – 8 p.m. ET; Saturday, 8 a.m. – 2 p.m. ET

If it's not covered, you have 2 options:

  • Request a list of similar covered drugs from Customer Care. Show the list to your doctor and ask them to prescribe from the list.
  • Ask Geisinger Gold to cover your drug with an exception. Follow the steps below to request an exception.

Prescription exceptions

You can ask Geisinger Gold to make an exception to our coverage rules. The types of exceptions you can request are:

  • Cover your drug even if it's not on our formulary.
  • Waive coverage restrictions or limits on your drug. For example, if there's a quantity limit, you can request to have it waived.

We'll generally approve an exception if the alternative drug is on the plan's formulary or if more restrictions would be less effective or cause adverse effects.

  • Contact us to request an initial coverage decision for a formulary, tiering or utilization restriction exception.
  • For initial decisions or exceptions, provide a statement from your physician. Decisions are made within 72 hours, or 24 hours for expedited requests.

Request an exception

Complete the CMS Request for Medicare Prescription Drug Determination form (updated 04/19/2006) and GHP Formulary Exception / Prior Authorization Request form (updated 09/12/2024).

  • Mail:

    Geisinger Gold
    Pharmacy Department
    100 N. Academy Ave.
    Danville, PA 17822-3045

  • Fax:

    570-271-5610

  • Phone requests, status updates or to request an expedited decision:
    • 800-988-4861, Monday – Friday, 8 a.m. – 8 p.m. ET
    • TDD/TTY: 711, Monday – Friday, 8 a.m. – 4:30 p.m. ET

Appeal a denial

Complete and send the CMS Redetermination form (updated 12/29/2024) to us.

  • Mail:

    Geisinger Gold
    Appeal Department
    100 N. Academy Ave.
    Danville, PA 17822-3220

  • Fax:

    570-271-7225 

Review process timeframe

Standard (7-day review) appeals must be submitted in writing. However, if your life, health or ability to regain maximum function is at risk, you, your representative or your prescribing physician can verbally request an expedited appeal.

  • Oct. 1 – March 31: Call 800-498-9731 daily from 8 a.m. to 8 p.m. ET.
  • April 1 – Sept. 30: Call 800-498-9731 Monday – Friday, 8 a.m. to 8 p.m. ET; Saturday, 8 a.m. – 2 p.m. ET (TTY: 711).

Medication Therapy Management

Medication Therapy Management, or MTM, is a program provided by pharmacists and other healthcare professionals to help you get the most out of your medications. Through the program, we'll review your over-the-counter and prescription medications and educate you on the right way to use them. We'll also look for drug interactions and possible ways you can save on costs.

You'll be automatically enrolled in the MTM program if you:

  • Have any three of the following conditions:
    Alzheimer's Disease, Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis), Chronic congestive heart failure, Diabetes, Dyslipidemia, End-stage renal disease, Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS), Hypertension, Mental health (including depression, schizophrenia, bipolar disorder and other chronic/disabling mental health conditions), Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
  • Are taking eight or more chronic/maintenance medications covered by Medicare Part D
  • Have a total medication cost of at least $1,623

OR

  • You've been enrolled in our Drug Management Program as an at-risk beneficiary

If you have Part D coverage and don’t meet these criteria, you can still request enrollment in the program.

If you'd like more information about the MTM program, call us toll-free at 800-988-4861 (TTY: 711). We're ready to answer your questions on weekdays from 8 a.m. to 4:30 p.m. ET.

MTM process

Eligible patients are notified by mail and receive a follow-up call to complete the review or schedule an appointment. MTM sessions usually last 15 to 30 minutes but can be extended if needed.

Program cost

This program is included free of charge as part of your Medicare Part D prescription coverage and is not considered a benefit.

Services

During the MTM consultation, the pharmacist will:

  • Review your prescription and over-the-counter medications
  • Discuss side effects and drug interactions
  • Discuss proper use of your medications
  • Tell you about potential cost savings

After the call, you'll get a personalized medication list.

See sample medication list and to-do list.

Our pharmacists will continue to monitor your medications for the rest of the year using Targeted Medication Reviews (TMRs). We may contact you or your provider if we identify additional opportunities to help you use your medications better or enhance your care.

Participation requirement

Participation is voluntary. To withdraw, call 800-988-4861 (TTY: 711), weekdays, 8 a.m. to 4:30 p.m. ET.

Remember, this program is at no cost to you — and it lets us work with your doctor to be sure you're getting the best care possible.

Drug transition policy

As a new or continuing member, you may be taking drugs that are not on our formulary or have usage limits. For example, you may need a prior authorization from us before you can fill your prescription. Consult your doctor to decide if you should switch to a covered drug or request a formulary exception.

While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

  • For each of your drugs not on our formulary, or if your ability to get your drugs is limited, we'll cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy.
  • After your first 30-day supply, we won't pay for these drugs, even if you've been a member of the plan for fewer than 90 days.

If you're a resident of a long-term care facility:

  • We'll allow you to refill your prescription until we've provided you with a 31-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days).
  • We'll cover more than 1 refill of these drugs for the first 90 days you are a member of our plan.
  • If you need a drug that's not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we’ll cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Medicare Prescription Payment Plan

Are you a Medicare member with high drug costs? You can spread your drug coverage and out-of-pocket drug costs across the year with the Medicare Prescription Payment Plan (M3P).

Learn more in this fact sheet from the Centers for Medicare and Medicaid Services.

For more information, call 833-696-2087 (TTY: 711) or visit the CMS website.

Contact us

Questions about exceptions, determinations or Medication Therapy Management?

Call the Gold Customer Care Team at 800-498-9731 (TTY: 711):

  • Oct. 1 – March 31, daily, 8 a.m. – 8 p.m. ET
  • April 1 – Sept. 30, Monday – Friday, 8 a.m. – 8 p.m. ET; Saturday, 8 a.m. – 2 p.m. ET

Manage your health with GHP member portal

Use the member portal to view claims and benefits, find a provider and more.

Manage your drug benefits

Signing in makes it easier and faster to search for prescription drug information related to your plan.

Geisinger Gold Medicare Advantage HMO, PPO, and HMO D-SNP plans are offered by Geisinger Health Plan/Geisinger Indemnity Insurance Company/Geisinger Quality Options, Inc., health plans with a Medicare contract. Continued enrollment in Geisinger Gold depends on contract renewal. Geisinger Health Plan, Geisinger Indemnity Insurance Company, and Geisinger Quality Options, Inc. are part of Geisinger, an integrated health care delivery and coverage organization. Risant Health is the parent organization of Geisinger.

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