Pharmacy forms and resources

Geisinger Gold (Medicare):

• Erythropoietin Stimulating Agents (ESA) Authorization Form
• Geisinger Gold/Medicare Vaccine Coverage
• Geisinger Gold Nonpar Provider Appeal Process Form
• Hepatitis C Pharmacy Benefit Drug Authorization Form
• Medical Benefit Outpatient Drug Authorization Form
• Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)
• Online Prior Authorization Portal (PromptPA)
• Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
• Universal Pharmacy Benefit Drug Authorization Form

Geisinger Health Plan/Geisinger Marketplace (Commercial):

• Erythropoietin Stimulating Agents (ESA) Authorization Form
• Hepatitis C Pharmacy Benefit Drug Authorization Form
• Medical Benefit Outpatient Drug Authorization Form
• Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)
• Non-Preferred Buprenorphine Pharmacy Benefit Drug Authorization Form
• Online Prior Authorization Portal (PromptPA)
• Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
• Specialty Drug List
• Specialty Prescription Referral Form
• Universal Pharmacy Benefit Drug Authorization Form

GHP Family (Medicaid):

• Medical Benefit Outpatient Drug Authorization Form
  
• Medical Drug Prior Authorization List (GHP Family - Medicaid)
• Online Prior Authorization Portal (PromptPA)
• Specialty Drug and Pharmacy List
• Specialty Prescription Referral Form
• Universal Pharmacy Benefit Drug Authorization Form

Statewide PDL forms:

• Acne Agents, Oral
• Alzheimers Agents PEAP
• Analgesics, Non-Opioid Barbiturate Combinations PEAP
• Analgesics, Opioids Long-Acting PEAP
• Analgesics, Opioids Short-Acting PEAP
• Androgenic Agents PEAP
• Antibiotics, GI - Dificid PEAP
• Antibiotics, GI - Xifaxan PEAP
• Antibiotics, GI - Zinplava PEAP
• Antidepressants, Other PEAP
• Antifibrotic Respiratory Agents (previously Idiopathic Pulmonary Fibrosis) 
• Antihemophilia Agents PEAP
• Antihyperuricemics - Colchicine PEAP
• Antihyperuricemics - Krystexxa PEAP
• Antimigraine Agents, Other - Acute Treatments PEAP
• Antimigraine Agents, Other - CGRP Inhibitors PEAP
• Antipsychotics PEAP
• Antivirals, CMV – Livtencity, Prevymis
• Benzodiazepines PEAP
• Bile Salts - Cholbam, Ocaliva
• Blood Glucose Meters and Test Strips PEAP
• Bone Density Regulators - Evista PEAP
• Bone Density Regulators Evenity, Forteo, Teriparatide, Tymlos PEAP
• Bone Density Regulators PEAP
• Botulinum Toxins PEAP
• Colony Stimulating Factors PEAP
• COPD Agents - Daliresp PEAP (not related to P&T; generic Daliresp now available)
• Cytokine and CAM Antagonists PEAP
• Dupixent PEAP
• Enzyme Replacements, Gaucher Disease PEAP
• Erythropoiesis Stimulating Proteins PEAP
• GI Motility, Chronic
• Growth Hormones PEAP
• Hepatitis C Agents Standard Request Form
• Hereditary Angioedema Agents PEAP
• Immunomodulators, Atopic Dermatitis
• Immunosuppressives, Oral - Lupkynis PEAP
• Intra-Articular Hyaluronates PEAP
• Iron Chelating Agents PEAP
• Lipotropics, Other
• Macular Degeneration Agents PEAP
• Monoclonal Antibodies - Anti-IL, Anti-lgE, Anti-TSLP
• Multiple Sclerosis PEAP
• NSAIDs - Ketorolac PEAP
• Obesity Treatment Agents
• Oncology Agents, Oral PEAP
• Opioid Dependence Treatments
• Pituitary Suppressive Agents, LHRH PEAP
• Potassium Removing Agents PEAP
• Progestational Agents - Makena PEAP
• Proton Pump Inhibitors Less Than 6 y.o. PEAP
• Pulmonary Arterial Hypertension Agents PEAP
• Stimulants and Related - Other PEAP
• Stimulants and Related - Provigil Nuvigil PEAP
• Thalidomide and Derivatives PEAP
• Thrombopoietics PEAP
• Tysabri PEAP
• Urea Cycle Disorder Agents PEAP
• VMAT2 Inhibitors PEAP
• Zeposia PEAP