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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 108.0 Kadcyla (ado-trastuzumab emtansine)
Kadcyla (ado-trastuzumab emtansine) is a HER2-targeted antibody and microtubule inhibitor conjugate..
Revised 5/8/23

MBP 86.0 Kalbitor (ecallantide)
Kalbitor (ecallantide) is a human plasma kallikrein inhibitor produced in Pichia pastoris yeast cells by recombinant DNA technology.
Revised 1/17/23

MBP 180.0 Kanuma (sebelipase alfa)
Kanuma (sebelipase alfa) is a form of enzyme replacement therapy that binds to cell surface receptors via glycans expressed on the protein and is subsequently internalized into lysosomes. Sebelipase alfa catalyzes the lysosomal hydrolysis of cholesteryl esters and triglycerides to free cholesterol, glycerol, and free fatty acids. In patients with lysosomal acid lipase (LAL) deficiency, replacement with sebelipase alfa, a recombinant form of LAL, results in improvement in disease-related hepatic and lipid parameters.
Revised 2/20/23

MBP 119.0 Keytruda (pembrolizumab)
Keytruda (pembrolizumab) binds to the programmed death receptor-1 (PD-1) ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells, inhibits T cell proliferation and cytokine production.
Revised 7/31/23

MBP 206.0 Khapzory (Levoleucovorin)
Khapzory (Levoleucovorin) is a chemotherapy modulating agent, folate analog. Levoleucovorin counteracts the toxic (and therapeutic) effects of folic acid antagonists (eg, methotrexate) which act by inhibiting dihydrofolate reductase. Levoleucovorin is the levo isomeric and pharmacologic active form of leucovorin (levoleucovorin does not require reduction by dihydrofolate reductase). A reduced derivative of folic acid, leucovorin supplies the necessary cofactor blocked by methotrexate. Leucovorin enhances the activity (and toxicity) of fluorouracil by stabilizing the binding of 5-fluoro-2’-deoxyuridine-5’-monophosphate (FdUMP; a fluorouracil metabolite) to thymidylate synthetase resulting in inhibition of this enzyme.
Revised 10/2/23

MBP 250.0 Kimmtrak (tebentafusp-tebn)
Tebentafusp-tebn is a bispecific T-cell engager; it consists of a soluble HLA-A*02:01-restricted T-cell receptor that is specific for the glycoprotein 100 (gp100) peptide and is fused to an anti-CD3 single-chain variable fragment. The T-cell receptor binds to a gp100 peptide presented by HLA-A*02:01 on the surface of uveal melanoma tumor cells. Once bound, they recruit and activate polyclonal T-cells (through CD3) to release inflammatory cytokines and cytolytic proteins, resulting in direct lysis of uveal melanoma tumor cells.
Revised 3/9/23

MBP 247.0 Kimyrsa (oritavancin)
Oritavancin is a lipoglycopeptide with concentration-dependent bactericidal activity. It inhibits cell wall biosynthesis by inhibiting the polymerization step by binding to stem peptides of peptidoglycan precursors, by inhibiting crosslinking by binding to bridging segments, and by disrupting bacterial membrane integrity, leading to cell death.
Revised 10/10/23

MBP 279.0 Korsuva (difelikefalin)
Korsuva (difelikefalin) is a kappa opioid receptor (KOR) agonist indicated for the treatment of moderate-to-severe pruritus associated with chronic kidney disease (CKD-aP) in adults undergoing hemodialysis (HD).  The relevance of KOR activation to therapeutic effectiveness is not known.
New Policy 5/16/23

MBP 272.0 Krystexxa (pegloticase)
Krystexxa (pegloticase) is a pegylated recombinant form of urate-oxidase enzyme, also known as uricase (an enzyme normally absent in humans and high primates), which converts uric acid to allantoin (an inactive and water soluble metabolite of uric acid); it does not inhibit the formation of uric acid.
New Policy 1/17/23

MBP 159.0 Kymriah (tisagenlecleucel)
Kymriah (tisagenlecleucel) 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 malignant and normal cells. The CAR is comprised of a murine single-chain antibody fragment which recognizes CD19 and is fused to intracellular signaling domains from 4-1BB (CD137) and CD3 zeta. CD3 zeta is a critical component for initiating T-cell activation and antitumor activity, while 4-1BB enhances expansion and persistence of tisagenlecleucel. After binding to CD19-expressing cells, the CAR transmits a signal to promote T-cell expansion, activation, target cell elimination, and persistence of the tisagenlecleucel cells. Tisagenlecleucel is prepared from the patient's peripheral blood cells obtained via leukapheresis. 
Revised 8/22/23

MBP 97.0 Kyprolis (carfilzomib)
Kyprolis (carfilzomib) is a tetrapeptide epoxyketone protease inhibitor that irreversibly binds to the N-terminal threonine – containing active sites of the 20S proteasome, the proteolytic core particle within the 26S proteasome.
Revised 8/22/23

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