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