Skip to main content

Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

Choose a letter to view policies by first letter:

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

G

MBP 198.0 Gamifant (emapalumab-lzsg)
Gamifant (emapalumab-lzsg) is an interferon gamma (IFNγ) blocking monoclonal antibody. IFNγ is hypersecreted in hemophagocytic lymphohistiocytosis (HLH); emapalumab binds to IFNγ and neutralizes it.
Reviewed 1/28/21

MBP 113.0 Gazyva (obinutuzumab)
Gazyva (obinutuzumab) is a monoclonal antibody that targets CD20 antigen that is expressed on the surface pf pre-B and mature B-cell lymphocytes.
Reviewed 8/26/20

MBP 211.0 Givlaari (givosiran)
Givlaari (givosiran) is a double-stranded small interfering RNA that causes degradation of aminolevulinate synthase 1 (ALAS1) mRNA in hepatocytes through RNA interference, reducing the elevated levels of liver ALAS1 mRNA.  The reduction of ALAS1 mRNA decreases circulating levels of neurotoxic intermediates aminolevulinic acid (ALA) and porphobilinogen (PBG), which are factors associated with attacks and other disease manifestations of acute hepatic porphyria (AHP).
Reviewed 4/30/21

Related information

Learn more about Geisinger Health Plan.

Prior authorizations

Log in to NaviNet to access and view prior authorization information.

Clinical guidelines

Clinical guidelines offer providers consistent and appropriate guidance for diagnosis and treatment of specific conditions or diseases.

Terms and conditions

View GHP’s terms and conditions.

Questions? Contact us

If you have questions or need more information, contact Geisinger Health Plan.