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Geisinger Health Plan Pharmacy Policy Updates – May 2018

Click here to view the Geisinger Health Plan Pharmacy Policy Updates »

May 2018 Pharmacy Policy Updates:

  • MBP 4.0 Intravenous Immune Globulin (IVIG)- Updated policy
  • MBP 5.0 Remicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximab-abda)- Updated policy
  • MBP 13.0 Viscosupplementation using hyaluronan injections (Euflexxa, Gel-One, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Visco-3)- Updated policy
  • MBP 40.0 Orencia IV (abatacept)- Updated policy
  • MBP 54.0 Soliris (eculizumab)- Updated policy
  • MBP 74.0 Cimzia (certolizumab pegol)- Updated policy
  • MBP 75.0 Stelara (ustekinumab)- Updated policy
  • MBP 112.0 Simponi Aria (golimumab)- Updated policy
  • MBP 126.0 Opdivo (nivolumab)- Updated policy
  • MBP 131.0 Cosentyx (secukinumab) vials – Updated policy
  • MBP 158.0 Tepadina (thiotepa)- Updated policy
  • MBP 165.0 Rituxan Hycela (rituximab/hyaluronidase)- Updated policy
  • MBP 169.0 Baxdela IV (delafloxacin) – New policy
  • MBP 170.0 Lutathera (lutetium Lu 177 dotatate)- New policy
  • MBP 171.0 Varubi IV (rolapitant)- New policy
  • MBP 172.0 Trisenox (arsenic trioxide)- New policy

The following policies were reviewed with no changes:

  • MBP 60.0 Cerezyme (imiglucerase)
  • MBP 61.0 Flolan or Veletri (epoprostenol)
  • MBP 63.0 Ixempra (ixabepilone)
  • MBP 64.0 Arranon (nelarbine)
  • MBP 65.0 Torisel (temsirolimus)
  • MBP 67.0 Supprelin LA (histrelin acetate implant)
  • MBP 79.0 Provenge (sipuleucel-T)
  • MBP 81.0 Prolia (denosumab)
  • MBP 83.0 Lumizyme (alglucosidase alfa)
  • MBP 85.0 Cinryze (C1 esterase inhibitor, human)
  • MBP 86.0 Kalbitor (ecallantide)
  • MBP 89.0 Xgeva (denosumab)
  • MBP 90.0 Benlysta (belimumab)
  • MBP 92.0 Off-label Drug Use for Oncologic Indications
  • MBP 93.0 Nulojix (belatacept)
  • MBP 95.0 Erwinaze (aspiraginase)
  • MBP 96.0 Voraxaze (glucarpidase)
  • MBP 99.0 Sandostatin LAR (Octreotide acetate)
  • MBP 100.0 Elelyso (taliglucerase alfa)
  • MBP 101.0 Zaltrap (ziv-aflibercept)
  • MBP 102.0 Synribo (omacetaxine mepesuccinate)
  • MBP 105.0 VPRIV (velaglucerase alfa)
  • MBP 108.0 Kadcyla (ado-trastuzumab emtansine)
  • MBP 111.0 Marqibo (vincristine sulfate liposome injection)
  • MBP 117.0 Beleodaq (belinostat)
  • MBP 118.0 Entyvio (vedolizumab)
  • MBP 124.0 Ruconest (C1 esterase inhibitor, recombinant)
  • MBP 127.0 Makena (hydroxyprogesterone caproate)
  • MBP 129.0 Iluvien (fluocinolone acetonide)
  • MBP 130.0 Mircera (methoxy polyethylene glycol-epoetin beta)


Click here to view the Geisinger Health Plan Pharmacy Policy Updates »


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