Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 155.0 Ocrevus (ocrelizumab)
Ocrevus (ocrelizumab) is an anti-CD20 monoclonal antibody. The precise mechanism of ocrelizumab is unknown, but presumed to involve binding to CD20, a cell surface antigen present on pre-B and mature B lymphocytes. Following cell surface binding to B lymphocytes, ocrelizumab results in antibody-dependent cellular cytolysis and complement-mediated lysis.
MBP 92.0 Off-label Drug Use for Oncologic Indications
Off-label use of a drug or biologic may be determined to be medically necessary and medically accepted for an oncologic indication not included in the FDA approved labeling if it is supported in one or more drug compendia; is not specifically contraindicated, unsupported, or not recommended; and is supported by published clinical research data.
MBP 229.0 Olinvyk (oliceridine)
Olinvyk (oliceridine) is an opioid agonist that selectively binds to the G-protein section of the opioid mu receptor to induce analgesia. Reduced activation of the beta-arrestin pathway associated with opioid-related adverse events (eg, respiratory depression, GI effects).
MBP 292.0 Omisirge (omidubicel-onlv)
Omisirge (omidubicel-onlv) is a nicotinamide (NAM) modified allogeneic hematopoietic progenitor cell therapy derived from cord blood used as an allogeneic stem cell donor source. Omisirge is manufactured utilizing a proprietary NAM based technology producing enriched HPCs. NAM technology overcomes the induction of accelerated proliferation, differentiation, cellular stress and signaling pathways that are typically activated when HPCs are removed from their natural environment. Ex-vivo culturing of cord blood derived HPCs in the presence of NAM leads to preservation of their stemness, homing to the bone marrow (BM) and retained engraftment capacity as demonstrated by rapid neutrophil engraftment and multi lineage immune reconstitution as observed in the clinical trials with Omisirge.
New Policy 7/18/23
MBP 138.0 Onivyde (irinotecan liposome injection)
Onivyde (irinotecan liposome injection) is a topoisomerase inhibitor indicated, in combination with fluorouracil and leucovorin, for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy.
MBP 188.0 Onpattro (patisiran)
Onpattro (patisiran) is a double-stranded small interfering ribonucleic acid (siRNA) that causes degradation of mutant and wild-type transthyretin (TTR) mRNA through RNA interference, which results in a reduction of serum TTR protein and TTR protein deposits in tissues. Serum TTR is a carrier of retinol binding protein, which is involved in the transport of vitamin A in the blood.
MBP 126.0 Opdivo (nivolumab)
Opdivo (nivolumab) is a fully human immunoglobulin G4 (IgG4) monoclonal antibody that selectively inhibits programmed cell death 1 (PD-1) activity by binding to the PD-1 receptor to block the ligands PD-L1 and PD-L2 from binding. The negative PD-1 receptor signaling that regulates T-cell activation and proliferation is therefore disrupted. This releases PD-1 pathway-mediated inhibition of the immune response, including the antitumor immune response.
MBP 257.0 Opdualag (nivolumab and relatlimab-rmbw)
Relatlimab is a human IgG4 monoclonal antibody that binds to the LAG-3 receptor (Tawbi 2022) and blocks interaction between LAG-3 and its ligands (including MHC II) to reduce LAG-3 pathway-mediated immune response inhibition; antagonism of this pathway promotes T cell proliferation and cytokine secretion. Nivolumab is a human IgG4 monoclonal antibody that binds to the PD-1 receptor and blocks interaction with its ligands PD-L1 and PD-L2 and reduces PD-1 pathway mediated inhibition of the immune response, including the anti-tumor immune response. Binding of the PD-1 ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells inhibits T-cell proliferation and cytokine production. Upregulation of PD-1 ligands occurs in some tumors; therefore, signaling through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors. In animal tumor models, blocking PD-1 activity resulted in decreased tumor growth and blocking LAG-3 potentiated the antitumor effect of PD-1 blockade (inhibiting tumor growth and promoting tumor regression). Combining nivolumab (anti-PD-1) and relatlimab (anti-LAG-3) results in increased T-cell activation compared to the activity of either antibody alone.
MBP 40.0 Orencia IV (abatacept)
Orencia (abatacept) is a selective T-cell co-stimulation modulator that inhibits T-cell activation by binding to CD80 and CD86 which blocks interaction with CD28. The interaction provides a co-stimulatory signal necessary for full activation of T-lymphocytes. Activated T-lymphocytes are found in the synovium of patients with rheumatoid arthritis (RA) and are implicated in the pathophysiology of RA.
MBP 234.0 Oxlumo (lumasiran)
Oxlumo (lumasiran) is a hydroxyacid oxidase 1 (HAO1)-directed small interfering ribonucleic acid (siRNA) that reduces the amount of available glyoxylate, a substrate for oxalate production, by targeting hydroxyacid oxidase 1 (HAO1) messenger RNA in hepatocytes through RNA interference, subsequently decreasing glycolate oxidase enzyme levels.
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