Learn what common pharmacy benefit terms mean so you can make the most of your benefits.
- Formulary – A list of drugs selected by Geisinger Health Plan which represents medications believed to be a necessary part of a quality treatment program.
- Brand name drug – A drug developed and patented by a specific company.
- Generic drug – A drug approved by the FDA as having the same active ingredient as the brand name drug and is just as safe and effective. Generally, generic drugs cost less than brand name drugs.
- Copay – How much you pay for a covered drug
- Deductible – How much you pay before we begin to pay
- Participating pharmacy – A pharmacy in our network
Important pharmacy terms
Certain medications are intended for use in members who are over or under a certain age. If a member doesn’t meet this age, the doctor prescribing the medication must send documentation to the Geisinger Health Plan Pharmacy Department.
Formulary addition request
This type of 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 Health Plan Pharmacy Department.
These are medications a health insurance plan won't cover under any circumstance. Exclusions can include:
- Over-the-counter medications
- Medications used for experimental, investigational or unproven therapies
- Medications used for cosmetic purposes
Some prescription drugs are available through the mail. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition.
Depending on your plan type mail order benefits may vary. Not all members can use mail order; for example, GHP Family members can’t receive drugs by mail.
To find out if your prescription can by ordered through the mail, contact Customer Service at 800-988-4861.
Formularies are designed to meet the needs of most members under a health insurance plan. Sometimes, however, a formulary may not include a medication that you need.
When this happens, the doctor prescribing the prescription may ask the Health Plan Pharmacy Department for an exception to be made. Physicians may call or fax our form.
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 patient can fill the prescription.
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.
Health insurance plans set limits on the amount of a medication they will 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.
A process that requires a member 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 involve step therapy.
Specialty drugs and pharmacies
Specialty drugs are usually very expensive prescription drugs that treat complex conditions and require special handling and administration.
Usually, this type of drug requires prior authorization and may have to be ordered through a specialty pharmacy.
In addition to handling specialty drugs, specialty pharmacies coordinate patient care and disease management for chronic and complex conditions.
Learn more about Geisinger Health Plan.