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Geisinger Gold members

Make the most of your membership! Our goal is to provide you with the best healthcare coverage available — and the best customer service. We're glad you're with us, and we're here to serve you. 

Looking for information about benefit documents or how to pay your bill? Click the links below.

Download your 2019 benefit documents. All files are PDFs.

Annual Notice of Change (ANOC)

If you are a current Geisinger Gold member and will remain enrolled for 2019, view your 2019 Annual Notice of Change (ANOC) letter.
Evidence of Coverage

Classic Advantage (HMO) (Columbia, Luzerne, Montour, Northumberland, Schuylkill, Snyder, Union counties)
Classic Advantage (HMO) (all other counties)
Classic Advantage Rx (HMO) (Columbia, Luzerne, Montour, Northumberland, Schuylkill, Snyder, Union counties)
Classic Advantage Rx (HMO) (all other counties)
Classic Complete Rx (HMO) (Columbia, Luzerne, Montour, Northumberland, Schuylkill, Snyder, Union counties)
Classic Complete Rx (HMO) (all other counties)
Classic Essential Rx (HMO)
Preferred Advantage Rx (PPO)
Preferred Complete Rx (PPO)
Preferred Enhanced Rx (PPO)
Secure Rx (HMO SNP)
PEBTF
Verizon

Plan Star Ratings from Centers for Medicare and Medicaid Services (CMS)

Pay your Geisinger Gold premium.

We want to make it easy for your to pay your premium, view your options below.

Online

If you're a current member, you can make a one-time payment or set up recurring payments through the member portal. Click here to log in.

By phone

You can call our free automated premium payment service at 844-639-3117. You'll need your contract ID or member ID, which can be found on your premium invoice or on you ID card. Note: if your ID number begins with zeroes or ends with 01, exclude them when entering your ID number.

If you would like to make a payment with the help of a representative, or if you have questions about your premium invoice, call 844-343-2639.

By mail

If you prefer to mail in your payment, please send your payment to the address below:

Geisinger Health Plan
P.O. Box 829703
Philadelphia, PA 19182

Need assistance?

Our Geisinger Gold Customer Care Team is here to help.

Our customer care team is here to help.

Coverage decisions and appeals

At GHP, we'll work with you to make sure you're satisfied with your health coverage. A coverage decision is a decision we make about your benefits and coverage, or about the amount we'll pay for your medical services. Have a question about a decision we made? Follow the steps below:

Step 1: Request a coverage decision

Start by calling, writing, or faxing us to request coverage for the medical care you want. You, your doctor or your representative can do this.

Call: 800-544-3907 (FREE) (TDD: 711)

Fax: 570-271-5534

Write: 
Geisinger Gold
Medical Management Department
100 North Academy Avenue
Danville, PA 17822-3218

Generally, we use the standard deadlines for giving you our decision. For a standard coverage decision, we’ll answer within 14 days after receiving your request.

If your health requires a quick response, request a “fast coverage decision.” A fast coverage decision means we’ll answer within 72 hours.

To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision only if you’re asking for coverage for medical care you have not yet received. (You can’t get a fast coverage decision if your request is about payment for medical care you’ve already received.)
  • You can get a fast coverage decision only if using standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast coverage decision.

If we decide that your medical condition doesn’t meet the requirements for a fast coverage decision, we’ll send you a letter that says so (and we’ll use the standard deadlines instead). The letter will tell you:

  • If your doctor asks for the fast coverage decision, we’ll automatically give a fast coverage decision.
  • How you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested

Note: We can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we’ll tell you in writing. If you believe we shouldn’t take extra days, you can file a “fast complaint” about our decision to take the extra days. When you file a fast complaint, we’ll answer your complaint within 24 hours.

Step 2: We consider your request and respond

Deadlines for fast coverage decisions
Generally, for a fast coverage decision, we’ll give you our answer within 72 hours.

  • As explained above, we can take up to 14 more calendar days under certain circumstances. If we decide to take extra days to make the coverage decision, we’ll tell you in writing.
  • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we’ll give you an answer to your complaint within 24 hours.
  • If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we’ll send you a detailed written explanation as to why we said no.

Deadlines for standard coverage decisions
Generally, for a standard coverage decision, we’ll give you our answer within 14 days of receiving your request.

  • We can take up to 14 more calendar days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the coverage decision, we’ll tell you in writing.
  • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we’ll give you an answer to your complaint within 24 hours.
  • If we don’t give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal. Step 3 below explains how to make an appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we’ll send you a written statement that explains why we said no.

Step 3: If we say no, you decide if you want to appeal

Appeals information
If we say no, you have the right to ask us to reconsider this decision by making an appeal. Making an appeal means trying again to get the medical care coverage you want. If you would like to appeal a denial for coverage or payment of services, you may appeal this denial by contacting Geisinger Gold at the following address:

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

Fax: 570-271-7225

In person
Geisinger Health Plan
108 Woodbine Lane
Danville, PA 17821

Standard service and payment appeals must be submitted in writing. However, when the member’s life, health or ability to regain maximum function is jeopardized by utilizing the standard appeal process, an expedited appeal may be requested verbally by the member, member representative, or provider by calling 800-498-9731 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (February 15 - September 30) or seven days a week (October 1 - February 14).

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 any complaint you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we can’t resolve your complaint over the phone, we have a formal procedure to review your complaints, 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 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (February 15 - September 30) or seven days a week (October 1 - February 14).

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

Fax: 570-271-7225

You may also contact Medicare directly by filling out this form on the Medicare website.

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

Expedited (Fast) Grievances can be initiated or requested when you disagree with the time frames Geisinger Gold establishes for making organization determinations (coverage decisions) or reconsiderations (appeals) for services you have not yet received.

Expedited (Fast) Grievances can be requested or filed by contacting the Geisinger Gold Customer Service Team at 800-498-9731 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (February 15 - September 30) or seven days a week (October 1 - February 14).

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.



Have questions?

If you have questions about the grievance, organization determination, or appeals processes, or to obtain an aggregate number of grievances and appeals filed with the plan, please call the Gold Customer Care Team at 800-498-9731 (TTY: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (February 15 - September 30) or seven days a week (October 1 - February 14).

Prescription exceptions and appeals

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.

2019 pharmacy prior authorization policies standard Rx | $0 deductible Rx (effective 9/1/19)
2019 step therapy policies standard Rx | $0 deductible Rx (effective 9/1/19)

Updated 8/30/19

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.

Coverage re-determinations 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. 1 - Feb. 14; for all other dates, call from 8 a.m. – 8 p.m., EST. Monday – Friday (TTY: 711)

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.

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. 1 - 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.

You may also contact Medicare directly by filling out this form on the Medicare website. 

 

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 time frame 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. 1 - 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.

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 31-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

Disenrollment rights and responsibilities

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.



Have questions?

If you have questions about the grievance, organization determination, or appeals processes, or to obtain an aggregate number of grievances and appeals filed with the plan, please call the Gold Customer Care Team at 800-498-9731 (TTY: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (February 15 - September 30) or seven days a week (October 1 - February 14).

 

 

Geisinger Gold Medicare Advantage HMO, PPO, and HMO SNP plans are offered by Geisinger Health Plan/Geisinger Indemnity Insurance Company, health plans with a Medicare contract. Continued enrollment in Geisinger Gold depends on annual contract renewal.

Y0032_19213_1_C Accepted 8/5/19
Page last updated: 7/31/2019

Contact us today!

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Call 800-498-9731