Prescriptions: When there's a problem

Geisinger Gold covers many prescription medications, often with copays as low as $3. Sometimes your doctor writes a prescription that our policy won’t cover. Learn how you can work with us to try to fix the situation.

Geisinger Gold exceptions and appeals information

Coverage determinations/exceptions
Coverage redeterminations/appeals
Appointment of representative
Grievances
Transition policy
Disenrollment rights and responsibilities 
Contact information

2017 pharmacy prior authorization policies | standard Rx | $0 deductible Rx (effective 8/1/2017)
2017 step therapy policies | standard Rx | $0 deductible Rx (effective 8/1/2017)

Updated 7/26/17

This page is where you can find Geisinger Gold's coverage determination (including exceptions) and grievance and appeals processes.  For more information on grievance, coverage determination (including exceptions) and appeals processes, please go to the "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)" chapter of your plan's Evidence of Coverage.

 

Coverage determinations and exceptions

If your drug isn’t included in the formulary, first contact customer service and ask if your drug is covered. If you learn that Geisinger Gold doesn’t cover your drug, you have two options:

  • You can ask customer service for a list of similar drugs that are covered by Geisinger Gold. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that’s covered by Geisinger Gold.
  • You can ask Geisinger Gold to make an exception and cover your drug. See below for information about how to request an exception.

You can ask Geisinger Gold 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’s not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Geisinger Gold 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 more of it.

Generally, Geisinger Gold will only approve a request for an exception if the alternative drug is included on the Plan's formulary 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 us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you’re requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.

For an expedited coverage determination or exception, the turnaround time is 24 hours.

To request an expedited coverage determination or exception, call 800-988-4861, Monday through Friday, 8 a.m. – 8 p.m., EST. A TDD/TTY line is available at 711, Monday through Friday, 8 a.m. – 4:30 p.m., EST. Instructions for completing and submitting a Drug Coverage Determination

To request a Drug Coverage Determination, such as a coverage exception or prior authorization, view the CMS Request for Medicare Prescription Drug Determination form.

Print and complete the entire form, and mail it to:

Geisinger Gold
Pharmacy Department
100 North Academy Avenue
Danville, PA 17822-3045

If you prefer, you can fax it to 570-271-5610.

To submit a request by phone, or for process or status questions, call 800-988-4861 (FREE), Monday through Friday, 8 a.m. – 8 p.m., EST. A TDD/TTY line is available at 711, Monday through Friday, 8 a.m. – 4:30 p.m., EST.

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Coverage redeterminations and appeals

If you want to appeal a denial of a Drug Coverage Determination made by Geisinger Gold, view the CMS Redetermination form. This form includes information on the different kinds of appeals you can file.

Instructions for completing and submitting a Drug Coverage Redetermination/Appeal

Print and complete the entire form and mail it to:

Geisinger Gold
Appeal Department
100 North Academy Avenue
Danville, PA 17822-3220

If you prefer, you can fax it to 570-271-7225.

Standard (seven-day review) appeals must be submitted in writing. However, when the member's life, health, or ability to regain maximum function is jeopardized by utilizing the seven-day appeal process, an expedited appeal may be requested verbally by the member, member representative, or prescribing physician by calling 800-498-9731, seven days a week, from 8 a.m. – 8 p.m., EST. Oct. 15 - Feb. 14; for all other dates, call from 8 a.m. – 8 p.m., EST. Monday – Friday (TDD/TTY 711).

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Appointment of representative

An Appointment of Representative form is required to process an appeal from someone other than our member, except when the prescribing physician requests an expedited appeal. If you would like to appoint a representative to file an appeal on your behalf, view the CMS Appointment of Representative form.

Print and complete the entire form, and mail it to:

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

If you prefer, you can fax it to: 571-271-7225.

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Grievances

If you have a grievance, we encourage you to first call the Geisinger Gold Customer Service Team at the number below. We will try to resolve your grievance over the phone. If you request a written response to your phone grievance, we will respond in writing to you. If we’re not able to resolve the issue over the phone, we have a formal procedure to review grievances, called the grievance procedure.

We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Grievances can be submitted by calling the Gold Customer Service Team at  (800) 498-9731, seven days a week from 8 a.m. – 8 p.m., EST, Oct. 15 - Feb. 14; for all other dates, call from 8 a.m. – 8 p.m., EST, Monday – Friday (TDD/TTY 711).

Written grievances should be submitted to:

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

If you prefer, you can fax it to 570-271-7225.

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Expedited (Fast) Grievances

As a Geisinger Gold member, you have the right to file an Expedited (Fast) Grievance for services you haven’t yet received, by following the process listed below.

Expedited (Fast) Grievances can be initiated or requested when you disagree with the time frames Geisinger Gold establishes for making coverage determinations (coverage decisions) for services you haven’t yet received.

An Expedited (Fast) Grievance can also be initiated or requested when you disagree with Geisinger Gold's established timeframe when you have requested a redetermination (appeal) of a coverage decision.

There is one instance when you may file an Expedited (Fast) Grievance related to coverage determinations.

If you or your prescribing physician request an expedited 24-hour Coverage Determination and Geisinger Gold decides that your request more closely meets the criteria for a standard 72-hour Coverage Determination, you may disagree and file an Expedited (Fast) Grievance.

There is one instance when you may file an Expedited (Fast) Grievance related to requests for a redetermination (appeal) of a coverage determination.

If you or your physician request an expedited 72-hour redetermination and Geisinger Gold decides that your request more closely meets the criteria for a standard seven-day redetermination, you may disagree and file an Expedited (Fast) Grievance.

Expedited (Fast) Grievances can be requested or filed by contacting the Geisinger Gold Customer Service Team at 800-498-9731 seven days a week, from 8 a.m. – 8 p.m., EST, Oct. 15 - Feb. 14; for all other dates, call from 8 a.m. – 8 p.m., EST, Monday through Friday (TTY/TDD 711).

A medical director will review your Expedited (Fast) Grievance and you will receive a verbal notification of the decision within 24 hours of receipt of your request for an Expedited (Fast) Grievance. Additionally, a written response will be provided to you within 72 hours of the medical director's decision.

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Transition policy

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’s on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception, to see if we’ll cover the drug you take. 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 that’s not on our formulary, or if your ability to get your drugs is limited, we will 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 93-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We’ll cover more than one 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.

For enrollees being admitted to or discharged from a long term care (LTC) facility, the use of early refill edits will not be used. Such enrollees will be allowed to access an early refill of Part D covered medications upon admission or discharge from such facilities.

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Rights and responsibilities upon disenrollment

Ending your membership in Geisinger Gold may be voluntary (your own choice) or involuntary (not your own choice):

  • You might leave our plan because you’ve decided that you want to leave. 
  • There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. 
  • The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. 
  • There are also limited situations where you do not choose to leave, but we are required to end your membership. 

If you’re leaving our plan, you must continue to get your medical care through our plan until your membership ends.  

When can you end your membership in our plan? 

You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the annual Medicare Advantage Disenrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.

Your membership will usually end on the first day of the month after we receive your request to change your plan.

Until your membership ends, you must keep getting your medical services through our plan.

If you leave Geisinger Gold, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time, you must continue to get your medical care through our plan. 

If you’re hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you’re discharged (even if you’re discharged after your new health coverage begins). 

Geisinger Gold must end your membership in the plan if any of the following happens:

  • If you don’t stay continuously enrolled in Medicare Part A and Part B
    • If you move out of our service area for more than six months 
    • If you move or take a long trip, you need to call member services to find out if the place you are moving or traveling to is in our plan’s area. 
  • If you become incarcerated (go to prison) 
  • If you intentionally give us incorrect information when you’re enrolling in our plan, and that information affects your eligibility for our plan
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan
    • We cannot make you leave our plan for this reason unless we get permission from Medicare first.
  • If you let someone else use your membership card to get medical care   
    • If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
  • If you do not pay the plan premiums for two months
    • We must notify you in writing that you have two months to pay the plan premium before we end your membership.

Need more information?

If you have questions or would like more information on when we can end your membership:

  • Call Member Services at 800-498-9731 for more information.

We can’t ask you to leave our plan for any reason related to your health, what should you do if this happens?

If you feel that you’re being asked to leave our plan because of a health-related reason, you should call Medicare at 800-MEDICARE (800-633-4227 FREE). TTY users should call 877-486-2048 FREE. You may call 24 hours a day, seven days a week. 

You have the right to make a complaint if we end your membership in our plan 

If we end your membership in our plan, we must tell you in writing our reasons for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.

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Contact information

If you have questions about the grievance, coverage determination, or appeals processes, or to obtain an aggregate number of grievances, appeals, and exceptions filed with the plan, please call the Gold Customer Service Team at 800-498-9731 (TDD: 711), 8 a.m. – 8 p.m., EST, Monday through Friday (April-September) or seven days a week (October-March).

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Y0032_16356_1 CMS Approved

Updated 2/1/2017

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