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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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MBP 152.0 Bavencio (avelumab)
Bavencio (avelumab) is a fully human monoclonal antibody that binds to programmed death ligand 1 (PD-L1) to selectively prevent the interaction between the programmed cell death-1 (PD-1) and B7.1 receptors, while still allowing interaction between PD-L2 and PD-1.2 PD-L1 is an immune check point protein expressed on tumor cells and tumor infiltrating cells and down regulates antitumor T-cell function by binding to PD-1 and B7.1; blocking PD-1 and B7.1 interactions restores antitumor T-cell function.
Revised 9/15/20

MBP 169.0 Baxdela IV (delafloxacin)
Baxdela IV (delafloxacin) is a fluoroquinolone antibiotic that inhibits DNA gyrase (topoisomerase II) and topoisomerase IV enzymes, which are required for bacterial DNA replication, transcription, repair and recombination.
Reviewed 1/28/21

MBP 117.0 Beleodaq (belinostat) 
Beleodaq (belinostat) is a histone deacetylase inhibitor indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).
Reviewed 9/30/20

MBP 90.0 Benlysta (belimumab)
Benlysta (belimumab) is a B-Lymphocyte stimulator-specific (BLyS) inhibitor that blocks the binding of soluble BLyS, a B-cell survival factor, to its receptors on B cells which inhibits the survival of B-cells, including autoreactive B cells, and reduces the differentiation of b cells into immunoglobulin-producing plasma cells.
Reviewed 1/1/21

MBP 84.0 Berinert (C1 esterase inhibitor, human)
Berinert (C1 esterase inhibitor, human) is a plasma-derived C1 esterase inhibitor (human) indicated for the treatment of acute abdominal, facial, or laryngeal attacks of hereditary angioedema (HAE) in adult and adolescent patients. Berinert increases C1 inhibitor levels which play a role in the inflammatory process by inactivating its substrate by binding to the reactive site.
Reviewed 1/19/21

MBP 160.0 Besponsa (inotuzumab ozogamicin)
Besponsa (inotuzumab ozogamicin) is a humanized CD22-directed monoclonal antibody-drug conjugate which is composed of the IgG4 kappa antibody inotuzumab (which is specific for human CD22), a calicheamicin component (a cytotoxic agent that causes double-stranded DNA breaks), and an acid-cleavable linker that covalently binds the calicheamicin to inotuzumab. After the antibody-drug conjugate binds to CD22, the CD22-conjugate complex is internalized and releases calicheamicin. Calicheamicin binds to the minor groove of DNA to induce double strand cleavage and subsequent cell cycle arrest and apoptosis.
Reviewed 7/26/21

MBP 223.0 Blenrep (belantamab mafodotin-blmf)
Blenrep (belantamab mafodotin-blmf) is an afucosylated, humanized antibody-drug conjugate directed against B-cell maturation antigen (BCMA); BCMA is expressed on multiple myeloma cells but is mostly absent on naive and memory B cells. The antibody is conjugated by a protease-resistant maleimidocaproyl linker to microtubule-disrupting monomethyl auristatin F (MMAF). After binding to BCMA, belantamab mafodotin is internalized and MMAF is released via proteolytic cleavage, resulting in cell cycle arrest and apoptosis. In addition to MMAF-induced apoptosis, belantamab mafodotin causes tumor cell lysis through antibody-dependent cellular cytotoxicity and antibody-dependent cellular phagocytosis.
New Policy 10/22/20

MBP 128.0 Blincyto (blinatumomab)
Blincyto (blinatumomab) is a bispecific T-cell engager (BiTE) which binds to CD19 expressed on B-cells and CD3 expressed on T-cells. It activates endogenous T cells by connecting CD3 in the T-cell receptor complex with CD19 on B-cells (malignant and benign), thus forming a cytolytic synapse between a cytotoxic T-cell and the cancer target B-cell. Blinatumomab mediates the production of cytolytic proteins, release of inflammatory cytokines, and proliferation of T cells, which result in lysis of CD19-positive cells.
Revised 5/18/21

MBP 42.0 Boniva (ibandronate sodium) Intravenous
Boniva (ibandronate sodium) is a nitrogen-containing bisphosphonate that inhibits osteoclast-mediated bone resorption.
Reviewed 9/26/20

MBP 11.0 Botulinum Toxin and Derivatives (Botox, Dysport, Myobloc, Xeomin)
Botulinum toxin injections are used to treat various focal muscle spastic disorders. They produce presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. The resulting chemical denervation of muscle produces local paralysis and allows individual muscles to be weakened selectively.
Revised 1/19/21

MBP 228.0 Breyanzi (lisocabtagene maraleucel)
Breyanzi (lisocabtagene maraleucel) is a CD19-directed genetically modified autologous T-cell immunotherapy in which a patient's T-cells are reprogrammed with a transgene encoding a chimeric antigen receptor (CAR) to identify and eliminate CD19-expressing cells (malignant and normal). Lisocabtagene maraleucel has a defined composition of CD8-and CD4-positive CAR T-cells. CAR is comprised of an FMC63 monoclonal antibody-derived single chain variable fragment (scFv), IgG4 hinge region, CD28 transmembrane domain, 4-1BB (CD137) costimulatory domain, and CD3 zeta activation domain. CD3 zeta signaling initiates activation and antitumor activity, while 4-1BB (CD137) signaling enhances T-cell expansion. CAR binding to CD19 (expressed on cell surfaces) induces activation and proliferation of CAR T-cells, release of pro-inflammatory cytokines, and results in cytotoxic destruction of target cells. Lisocabtagene maraleucel is prepared from the patient's T-cells, which are obtained via leukapheresis.
New Policy 4/29/21

MBP 157.0 Brineura (cerliponase alfa)
Brineura (cerliponase alfa) is a proenzyme that, once activated, cleaves tripeptides from the N-terminus of proteins. This leads to the breakdown of lysosomal storage materials that otherwise accumulate in patients with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2), leading to progressive decline in motor function.
Reviewed 8/26/20

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