About pharmacy claims

Prescription drug coverage is a major part of health insurance for many individuals. We work with a team of healthcare providers to ensure that our covered medications are appropriate and up-to-date.

If you’re a member needing help with your pharmacy benefits, call us at 800-988-4861. (GHP Family members, call 855-552-6028.)

How we decide which drugs are covered

Geisinger Health Plan seeks to cover medications that are medically necessary and represent prescription therapies that are believed to be a vital part of a quality treatment program.

While that doesn’t mean every available drug is covered under a plan, it does mean that GHP works hard with healthcare providers and pharmacists to ensure the medications available in the formulary meets clinical needs, as well as health plan requirements.

Learn more about how we decide what drugs are covered.

What to do if a drug isn’t covered

When a prescription drug isn’t covered under our formulary, there are options available to health plan members if they need the drug, or their providers prefer that drug.

  • Formulary addition request: A doctor can submit 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.
  • Non-formulary medications: When our formulary doesn’t include a medication that an individual member needs—whether it's because of a specific allergy, a specific diagnostic-related need or because it no longer works for the member—your doctor may ask the Geisinger Health Plan pharmacy department for an exception to be made.
  • Prior authorization: Some medications have additional requirements or limits on how they're covered by a health plan. When a medication requires prior authorization, the doctor prescribing it has to get prior approval from Geisinger Health Plan before the patient can fill the prescription. Without prior approval, the health plan may not cover the drug.

Related information

Learn more about Geisinger Health Plan.

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