What's covered by GHP Family's Medical Assistance plan?
GHP Family coverage
Your health matters. Not just to you, but to us. That’s why GHP Family’s Medical Assistance Plan has you covered. You and your family will get robust benefits that cover the services you need, plus access to our wellness programs to keep you healthy.
Have questions about your health along the way? We’re here when you need us. No question is too big or too small. Call our customer care team at 855-227-1302 (PA Relay 711). They’re available:
Monday, Tuesday, Thursday and Friday: 7 a.m.- 7 p.m.
Wednesday: 7 a.m. – 8 p.m.
Saturday: 8 a.m. – 2 p.m.
Your plan has broad healthcare coverage, including:
Doctors and hospitals nearby
GHP Family has a network of contracted providers, facilities and suppliers to provide covered physical health services to members. Search for providers at Find Care - Geisinger Health Plan.
Maternity care
Prenatal care is the healthcare a person receives throughout pregnancy and delivery from a maternity care provider, such as an obstetrician or a nurse-midwife. Seek early, regular prenatal care for your and your baby’s health. Even if you’ve been pregnant before, see a maternity care provider regularly through each pregnancy.
Be sure to stay with the same maternity care provider throughout your pregnancy and postpartum care (one year after birth). They will watch your health and the health of your growing baby. It’s also a good idea to stay with the same HealthChoices plan during your entire pregnancy.
Routine checkups and immunizations
Having a physical exam with your primary care physician (PCP) at least once a year can uncover problems you may not know about. Your PCP may order tests based on your health history, age and sex. They will also check whether you need immunizations or preventive services to protect your health.
Prescription drugs
GHP Family covers pharmacy benefits that include prescription medicines and over-the-counter medicines and vitamins with a doctor’s prescription. When a provider prescribes a medication for you, you can take it to any pharmacy in the GHP Family’s network. Search for covered drugs at Benefits Preview (navitus.com).
Vision and dental care
Everyone needs regular eye exams. And with GHP Family, you don’t need to pick one eye doctor for all your appointments. You can go to any eye doctor in the GHP Family network.
Regular dentist visits keep your mouth healthy. Members are eligible to receive all medically necessary dental services. You don’t need a referral for a dentist visit. Our team of dental hygienists can provide dental education via phone, help you find a dentist and answer questions about oral health.
Emergency care
An emergency medical condition is an injury or illness so severe that a reasonable person with no medical training would believe there is immediate risk to a person’s life or long-term health. You don’t need approval from GHP Family for emergency services, and you may use any hospital or other setting for emergency care.
Behavioral health services
Behavioral health services include mental health services and substance use disorder services. They’re provided through behavioral health managed care organizations (BH-MCOs) overseen by the Department of Human Services’ Office of Mental Health and Substance Abuse Services (OMHSAS).
Search for behavioral health MCOs in your county.
Tobacco cessation
Ready to be tobacco-free? GHP Family is here to help. Options include medicine, counseling services, behavioral health treatment, case management programs and other tobacco cessation resources.
Find out what drugs are covered by GHP Family
GHP Family has a formulary, or a list of drugs covered under your plan. GHP Family covers medicine listed on the Statewide Preferred Drug List (PDL) and the GHP Family supplemental formulary.
Have questions or want a copy of the Statewide PDL and GHP Family’s supplemental formulary? Call GHP Family Pharmacy Customer Service at 855-552-6028 (PA Relay 711).
You can also download a copy of the Statewide PDL.
Your pharmacy benefits
Specialty Pharmacy/Specialty drugs
Do you need specialty medications? GHP Family uses Navitus Specialty Pharmacy Network. That means you can use any network specialty pharmacy. Find a list of Specialty Pharmacies and medications here.
You can use an out-of-network pharmacy:
- If the medications you need aren’t at a network pharmacy. This is called “limited distribution.” It’s when the drug maker only lets some pharmacies dispense their medication.
- If a network pharmacy can’t give you medications in time to prevent harm.
Taking a specialty medicine? Need to find a specialty pharmacy? Call 855-552-6028 or 570-214-3554 (PA Relay 711).
Hours:
Monday, Tuesday, Thursday, Friday: 8 a.m. – 7 p.m.
Wednesday: 8 a.m. – 8 p.m.
Saturday: 8 a.m. – 2 p.m.
Transition policy
Are you a new member? You may be taking medicine that isn’t on our formulary. Or maybe you’re taking one that is on our formulary, but it requires prior authorization.
Either way, you may need approval from GHP Family to get a drug that’s not listed on the formulary. Talk with your doctor to decide if you should switch to an appropriate formulary drug or request a formulary exception. While you find your best option, we will approve the service and honor the amount, duration/frequency and scope of the services for up to 60 days for members 21 and older. For members younger than 21, approval will be given for the course of treatment.
Prior authorization
GHP Family requires your physician to get prior approval for certain medications. This means your prescriber needs to get approval from GHP Family before you fill prescriptions for these drugs. Without this approval, GHP Family will not pay for the drug.
If you need prior authorization of your medication, you have two options:
Option 1
If your medication isn’t on the Statewide Preferred Drug List or GHP Family formulary, you can share the lists with your doctor. They can tell if you if there’s an alternative that will work for you.
Call GHP Family Pharmacy Customer Service at 855-552-6028 or 570-214-3554 (PA Relay 711).
Hours:
Monday, Tuesday, Thursday, Friday: 8 a.m. – 7 p.m.
Wednesday: 8 a.m. – 8 p.m.
Saturday: 8 a.m. – 2 p.m.
Option 2
Your doctor can ask GHP Family to approve your current drug through a prior authorization. See our Geisinger policy.
See the Statewide Preferred Drug List (PDL) – Prior authorization criteria.
No prescription limit
GHP Family doesn't limit the number of prescriptions you can receive each month. If you’re having trouble managing multiple prescriptions, a GHP Family pharmacist can help. They’ll work with you and your doctor to make it easier for you to stay on the medications you need.
Formulary updates
Pharmaceutical and therapy committee notes
GHP Family customer care
Questions about what’s covered by GHP? Call the GHP Family customer care team at 855-227-1302 (PA Relay 711).
We’re available:
Monday, Tuesday, Thursday and Friday: 7 a.m. – 7 p.m.
Wednesday: 7 a.m. – 8 p.m.
Saturday: 8 a.m. – 2 p.m.
Enhanced Member Supports Unit
We’re here to support you. Every GHP Family member can get help from the Enhanced Member Supports Unit (EMSU). Nurse case managers work with various healthcare providers and community resources to support your specific needs. Contact us if you need help managing your or your family member's complex health related matters. We can also help if you:
- Need help scheduling or getting to your medical appointments
- Take multiple prescription medications
- Have a child with special needs
Our staff can help you take the next step toward better health, like finding behavioral healthcare, scheduling healthcare appointments or connecting you with community agencies for added support. And they're just a call away, Monday through Friday, 8 a.m. to 5 p.m., at 855-214-8100 (PA Relay 711).
Programs for GHP Family Members
Our health and wellness programs can help you develop long-term healthy habits for life.
Member Rewards Program
Receive incentives for attending and completing certain doctor visits.
Telemedicine
We cover care by video or phone so you can get care when you need it.
Tel-A-Nurse
Talk with a nurse 24 hours a day, 7 days a week. Call 877-543-5061 (PA Relay 711).
Neighborly
Find free or reduced-cost services in your community at NeighborlyPA.com.
Text4Baby Program
Text messages sent at no cost to you that offer information about caring for newborns, tips to help pregnant women and new moms care for their own health. For more information, including a list of participating cell phone service carriers, visit text4b.com.
Nurse-Family Partnership
If you're having your first baby, this free program is available to you. A GHP Family nurse will visit you throughout your pregnancy and up until your child is 2 years old. Call 866-864-5226 or visit nursefamilypartnership.org for more information.
Healthy Kids Are Happy Kids
This program offers services to families with younger children, including information about important care and screenings.
Right From the Start
Join this no-cost program when you find out you're pregnant. Our nurses will guide you through a healthy pregnancy and will help you manage your appointments, including scheduling and transportation, or any other health needs you may have while you are pregnant.
Early and periodic screening diagnosis and treatment
Every child needs early and periodic screening diagnosis and treatment (EPSDT) exams, also called well visits. Your child's doctor will let you know when your child needs an EPSDT exam. Our quality improvement nurses can also help with your little one's EPSDT care. To speak with a nurse, call GHP Family Enhanced Member Supports Unit at 855-214-8100 (PA Relay 711).
GED Scholarship Program
Available to assist with the costs of getting your GED, including training materials, practice testing, the GED test and retests. Call the Customer Care Team at 855-227-1302 (PA Relay 711) to learn more.
You can help improve our services through the Health Education Advisory Committee. For more details or to join, call us at 855-214-8100 (PA Relay 711).
