Common pharmacy terms

Age restrictions

Some medications are intended for use by members who are over or under a certain age. If a member doesn’t meet this age requirement, the doctor prescribing the medication must send documentation to the Geisinger Health Plan Pharmacy Department.

Brand-name drug

A drug developed and patented by a specific company.

Copay/coinsurance

How much you pay for a covered drug.

Deductible

How much you pay before we begin to pay.

Formulary

A list of drugs selected by GHP representing medications believed to be a necessary part of a quality treatment program.

Formulary addition request

A doctor can submit a request for changes, additions, comments or suggestions related to a formulary. Formulary addition requests are usually made by written request to the Geisinger Health Plan Pharmacy Department.

Formulary exclusions

These are medications that a health insurance plan won't cover under any circumstance. Exclusions can include:

• Over-the-counter medications.
• Experimental, investigational or unproven therapies.
• Medications used for cosmetic purposes.

Generic drug

A drug approved by the FDA as having the same active ingredient as the brand-name drug. They’re just as safe and effective, and generally cost less than brand-name drugs.

Mail order

Some prescription drugs are available through the mail. The drugs provided through mail order are usually drugs taken on a regular basis for a chronic or long-term medical condition.

Depending on your plan type, mail-order benefits may vary but are usually quicker and much less expensive.

To find out if your prescription can be ordered through the mail:

• Call our mail-order pharmacy team at 844-878-5562.
• Learn more about switching to our mail-order pharmacy.

Non-formulary medications

Formularies are designed to meet the needs of most members under a health insurance plan. Sometimes, though, a formulary may not include a medication that you need.

When this happens, the doctor prescribing the prescription may ask the Geisinger Health Plan Pharmacy Department for an exception to be made. Physicians may call or fax our form for this.

Participating pharmacy

A pharmacy that’s part of the GHP network where you can receive covered medications, usually at a lower cost.

Prior authorization

Some medications in a formulary have additional requirements or limits on how they're covered by a health insurance plan. When a medication requires prior authorization, the doctor prescribing it has to get prior approval from Geisinger before the prescription can be filled.

Without prior approval, the health insurance plan may not cover the drug. It's a good idea to check your plan's formulary to see if any of your prescription drugs require prior authorization.

Quantity limits

Health insurance plans set limits on the amount of a medication they’ll cover over a certain period of time. These limits are set for safety and quality reasons. Both formulary and non-formulary drugs may have quantity limits.

Specialty drugs and pharmacies

Specialty drugs are prescription drugs that treat complex conditions and require special handling and administration. This type of drug is usually very expensive, requires prior authorization and may have to be ordered through a specialty pharmacy.

Besides handling specialty drugs, specialty pharmacies coordinate patient care and disease management for chronic and complex conditions.

Step therapy

A process that requires you to try certain medications to treat a medical condition first before the health insurance plan covers another drug for that same condition. Check your plan's formulary to see if any of your prescription drugs require step therapy.