How drugs get covered

The process for adding (or removing) prescription drugs from a formulary requires collaborative effort between Geisinger Health Plan, practicing physician and pharmacists representing various clinical specialties and even the Food and Drug Administration (FDA).

It’s all about the formulary

A formulary outlines the medications that are covered by your plan. Covered drugs costs and restrictions vary by plan.

A medication formulary is a continually updated list of prescription medications. It represents the medications currently covered based upon the clinical judgment of the Geisinger Health Plan Pharmacy and Therapeutics Committee, which is made up of pharmacists and physicians.

The committee thoroughly reviews medical literature to:

  • Determine which medications are likely to produce the best results for patients
  • If two or more medications produce the same clinical results, elements like cost and ease of use are considered

A well-developed formulary enhances quality of patient care by encouraging physicians to prescribe medications that are safe, effective and likely to achieve the best possible outcome for the patient.

 

A multitiered effort

Formularies usually have what’s known as tiers, or levels that represent a member’s cost for different types of drugs.

  • Lower tiers include medications that are generic
  • Higher tiers are either brand-name medications or specialty drugs, which are highly expensive medications for treating rare conditions

Several factors are considered when assigning medications to tiers:

  • Availability of a generic equivalent
  • Total cost of the medication
  • Cost of the medication relative to other medications that fall in the same therapeutic class (they treat some of the same conditions)
  • Availability of over-the-counter alternatives
  • Clinical and economic factors


When there’s a problem

You may not respond well to a given formulary medication in some situations, or you may have an allergy or other condition that requires the use of a non-formulary medication. An exception process exists for these special instances.

Your physician may initiate a request for a formulary exception by contacting our Pharmacy Service Team. Your request is reviewed, including review of pertinent medical records, treatment and laboratory data.

How exceptions are handled varies depending on your plan type. Log in for more details about your specific plan.

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