Prescription drug coverage
Brand name and generic drugs are included in our plan. By enrolling for coverage, you may even be able to save money on your medications.
2019 Opioid Policy Changes:
Opioid drugs have serious risks such as addiction, overdose and death. CMS is very concerned about the opioid epidemic and its effect on our communities and is committed to a complete strategy to combat this public health emergency. For 2019, several new drug management programs are being put in place to prevent and combat opioid overuse:
- Opioid prescriptions will be monitored for safe dosage levels. If one or more opioid prescription is above a safe dosage limit, the prescription will be stopped at the pharmacy for review by the provider to make sure that the prescription is medically necessary and appropriate.
- Opioid prescriptions that are taken together with benzodiazepine prescriptions will be stopped at the pharmacy for review by the provider to make sure that the prescriptions are medically necessary and appropriate.
- Members who have not had a recent prescription for opioids will be limited to no more than a seven-day supply for their first opioid prescription for the treatment of acute pain.
- Prescriptions for Long-Acting Opioids that are taken at the same time will be stopped at the pharmacy for review by the provider to make sure that the prescriptions are medically necessary and appropriate.
You may be exempt from these drug management programs if you:
- have an active cancer diagnosis
- have a diagnosis of sickle cell anemia
- are in a hospice or long-term care facility
For more information, contact the Pharmacy Service Team at 800-988-4861, seven days a week, 8 a.m. – 8 p.m., or 711 (TTY/TDD), seven days a week, 8 a.m. – 8 p.m.
You may also contact your provider with any medication related questions.
Find out which drugs are covered
View 2019 Drug Plan Formularies
Nearly 3,000 retail pharmacies
Our pharmacy network includes both large chain pharmacies and neighborhood drug stores throughout Pennsylvania. Geisinger Gold has contracts with pharmacies that meet or exceed CMS requirements for pharmacy access in your area.
What is Medication Therapy Management (MTM)?
- Medication Therapy Management (MTM) is a service provided by pharmacists and other healthcare professionals who have been trained to help patients manage their medications
- Our pharmacists work with your doctor to ensure you are receiving the best possible care
- This free and voluntary medication review is included as part of your Medicare Part D prescription coverage
MTM services are completed by Mirixa (Community Pharmacy Services) on behalf of Geisinger Health Plan.
Patients who meet the following criteria will be automatically enrolled in the MTM program:
- Three of the five following conditions: diabetes, high blood pressure, COPD, high cholesterol or osteoporosis
- Are taking seven or more medications to treat the previously mentioned chronic conditions
- Have a total medication cost of at least $4,044 annually
Patients with Part D coverage who do not meet the above criteria are still eligible to request enrollment in the program.
How does the program work?
- Throughout the year we will be automatically enrolling patients that meet the above criteria
- Once enrolled, you will receive a letter in the mail explaining the program and how to inform us of the best time to reach you
- If you do not contact us with a preferred time, one of our pharmacists will be calling you between the hours of 9 a.m. and 5 p.m. within a few weeks to months of receiving the letter
- At that time you will be able to either complete the medication review or schedule a future appointment if you are interested in participating
What services are offered?
Our MTM service provides a free, personal consultation with one of our highly trained pharmacists. The consultation is completed over the phone at a time that is convenient for you.
During the consultation, the pharmacist will:
- Review your prescription and over-the-counter medications
- Discuss side effects and drug interactions
- Discuss proper use of your medications
- Identify potential cost savings
After the call, you will be provided with a personalized medication list. Blank copies of the list can be printed by clicking here.
How to obtain more information
If you would like more information regarding this program, call us toll-free at 1-800-988-4861. Hours of operation are Monday through Friday between 9 a.m. and 5 p.m. EST.
Frequently asked questions
What is the cost of this program?
This program is included free of charge as part of your Medicare Part D prescription coverage and is not considered a benefit.
What is Medication Therapy Management (MTM)?
Medication Therapy Management (MTM) is a program provided by pharmacists and other health care professionals to help patients get the most out of their medications. The program includes a review of your over-the-counter and prescription medications while educating you on their proper use. Our pharmacists will also search for drug interactions and possible cost-saving opportunities.
How do I know if I’m eligible?
Our pharmacy team will be identifying eligible patients and will automatically enroll them throughout the year. These patients will receive notification in the mail informing them of their eligibility.
Am I required to participate?
Participation in this program is voluntary. If you would like to withdraw, contact Customer Service at 1-800-988-4861 between 8 a.m. and 8 p.m. EST, Monday through Friday. Remember that while this program is optional, it is of no cost to you and allows us to work with your doctor to ensure you are receiving the best care possible.
How much time will this take?
The average MTM session ranges from 15-30 minutes. However, we are more than happy to spend additional time discussing your medications and health-related concerns, if necessary.
Learn more about exceptions and appeals regarding your prescription coverage.
If you purchase a stand-alone Medicare drug plan while you're enrolled in a Medicare Advantage plan with prescription drug coverage (MAPD), you'll be automatically disenrolled from the MAPD plan.
Members must get their prescriptions from network pharmacies. In case of emergency, members may go to a non-network pharmacy. You may only enroll in one prescription drug plan at a time. If you are enrolled in a Medicare Advantage plan which offers prescription drug coverage, you must take your prescription drug coverage from that plan. You cannot enroll in a stand-alone prescription drug plan unless you disenroll from your Medicare Advantage plan. If you are enrolled in a Medical Savings Account plan you can enroll in a stand-alone prescription drug plan. Prescription drug coverage from Geisinger Gold is offered exclusively to Geisinger Gold members.
Geisinger Gold may add or remove drugs from our formulary during the year. For more information, contact the Pharmacy Service Team at 800-988-4861, seven days a week, 8 a.m. – 8 p.m., or 711 (TTY/TDD), seven days a week, 8 a.m. – 8 p.m.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a different tier, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Geisinger Gold covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call
- 1-800-MEDICARE (800-633-4227) TTY users should call 877-486-2048, 24 hours a day/7 days a week
- The Social Security Office at 800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 800-325-0778
- Your state Medicaid office
Y0032_18270_1_M File and Use 10/1/18
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