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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:



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 9/15/22

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 1/15/24

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).
Revised 9/22/22

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.
Revised 1/26/24

MBP 251.0 Beovu (brolucizumab)
Brolucizumab is a recombinant humanized monoclonal antibody vascular endothelial growth factor (VEGF) inhibitor that binds to the 3 major isoforms of VEGF-A, thereby suppressing endothelial cell proliferation, neovascularization, and vascular permeability to slow vision loss.
Revised 10/12/23

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 pediatric patients. Berinert increases C1 inhibitor levels which play a role in the inflammatory process by inactivating it’s substrate by binding to the reactive site.
Revised 11/15/23

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.
Revised 6/6/23

MBP 309.0 Bevacizumab (Avastin) and Biosimilars
Bevacizumab is a recombinant, humanized monoclonal antibody which binds to, and neutralizes, vascular endothelial growth factor (VEGF), preventing its association with endothelial receptors, Flt-1 and KDR. VEGF binding initiates angiogenesis (endothelial proliferation and the formation of new blood vessels). The inhibition of microvascular growth is believed to slow the growth of all tissues (including metastatic tissue).
New Policy 1/16/24

MBP 297.0 Beyfortus (nirsevimab-alip)
Beyfortus (nirsevimab-alip), a respiratory syncytial virus F protein-directed fusion inhibitor, is a human immunoglobulin G1 (IgG1) kappa monoclonal antibody with anti-respiratory syncytial virus activity.
New Policy 9/19/23 

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 3/21/23

MBP 42.0 Boniva (ibandronate sodium) Intravenous
Boniva (ibandronate sodium) is a nitrogen-containing bisphosphonate that inhibits osteoclast-mediated bone resorption.
Revised 4/25/23

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 3/19/24

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.
Revised 8/22/23

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.
Revised 8/18/23

MBP 295.0 Briumvi (ublituximab-xiiy)
Briumvi (ublituximab-xiiy) is a chimeric IgG monoclonal antibody directed against the CD20 antigen on pre-B and mature B lymphocytes. Ublituximab binds to CD20 and results in cell lysis via complement-dependent cytolysis and antibody-dependent cellular cytolysis. B-cells are thought to affect the pathophysiology of multiple sclerosis through antigen presentation, pro-inflammatory cytokine production, soluble toxic factor production, contribution to formation of ectopic lymphoid aggregates in the meninges, and by providing an Epstein-Barr virus infection reservoir.
New Policy 6/23/23

MBP 47.0 Byooviz (ranibizumab-nuna), Lucentis (ranibizumab), and Cimerli (ranibizumab-eqrn) 
Ranibizumab is a recombinant humanized monoclonal antibody fragment which binds to and inhibits human vascular endothelial growth factor A (VEGF-A). Ranibizumab inhibits VEGF from binding to its receptors and thereby suppressing neovascularization and slowing vision loss.
Revised 1/17/23

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