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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 256.0 Carvykti (ciltacabtagene autoleucel)
Ciltacabtagene autoleucel is a B cell maturation antigen (BCMA)-directed genetically modified autologous T-cell immunotherapy in which a patient's T cells are reprogrammed via transduction with a lentiviral vector to express an anti-BCMA chimeric antigen receptor (CAR). The CAR T-cell construct includes an anti-BCMA targeting domain consisting of a CD3-zeta signaling domain and a 4-1BB costimulatory domain. Ciltacabtagene autoleucel is prepared from the patient’s peripheral blood mononuclear cells (obtained via leukapheresis), which are enriched for T cells. When infused back into the patient, the anti-BCMA CAR T cells recognize and eliminate BCMA-expressing target cells. In addition to T cells, ciltacabtagene autoleucel may contain natural killer (NK) cells.
Revised 5/11/23

MBP 60.0 Cerezyme (imiglucerase)
Cerezyme (imiglucerase) is an analogue of the human enzyme ß-glucocerebrosidase, produced by recombinant DNA technology.
Revised 1/8/24

MBP 47.0 Cimerli (ranibizumab-eqrn), Lucentis (ranibizumab), and Byooviz (ranibizumab-nuna)
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

MBP 74.0 Cimzia (certolizumab pegol)
Cimzia (certolizumab pegol) is a tumor necrosis factor alpha (TNFα) inhibitor PEGylated humanized Fab fragment of an anti-tumor necrosis factor – α monoclonal antibody. It binds with high affinity to both membrane-bound and soluble TNFα and demonstrated neutralizing of cytokines.
Revised 1/9/24

MBP 145.0 Cinqair (reslizumab)
Cinqair (reslizumab) is an interleukin-5 antagonist (IgG4 kappa). IL-5 is the major cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils (a cell type associated with inflammation and an important component in the pathogenesis of asthma). Reslizumab, by inhibiting IL-5 signaling, reduces the production and survival of eosinophils; however, the mechanism of reslizumab action in asthma has not been definitively established.
Nucala is indicated as add-on maintenance therapy for patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.
Revised 6/6/24

MBP 85.0 Cinryze (C1 esterase inhibitor, human)
Cinryze (C1 esterase inhibitor, human) is indicated for routine prophylaxis against angioedema attacks in patients with Hereditary Angioedema.
Revised 11/7/23

MBP 191.0 Cinvanti (aprepitant)
Cinvanti (aprepitant) is a substance P/neurokinin 1 receptor antagonist which prevents acute and delayed vomiting by inhibiting the substance P/neurokinin 1 (NK1) receptor; augments the antiemetic activity of 5-HT3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemotherapy-induced emesis.
Revised 1/9/24

MBP 38.0 Clolar (clofarabine)
Clolar (clofarabine) is a purine nucleoside antimetabolite antineoplastic agent.
Revised 1/18/24

MBP 298.0 Columvi (glofitamab-gxbm)
Columvi (glofitamab-gxbm) is a bispecific T-cell engaging antibody that targets CD3 and CD20; a novel 2:1 tumor–T-cell binding configuration confers bivalency for CD20 and monovalency for CD3. Glofitamab binds to CD20 expressed on the surface of B-cells and to the CD3 receptor expressed on T-cell surfaces, resulting in T-cell activation and proliferation, cytokine secretion, and lysis of CD20-expressing B cells.
New Policy 9/19/23

MBP 232.0 Cosela (trilaciclib)
Cosela (trilaciclib) is a highly potent, selective, and reversible cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor. Hematopoietic stem and progenitor cell (HSPC) proliferation is dependent on CDK4/6 activity. Through CDK4/6 inhibition, trilaciclib transiently induces HSPC G1 cell cycle arrest, preventing the cells from proliferating in the presence of cytotoxic chemotherapy and thus resulting in myelopreservation
Revised 3/31/23

MBP 131.0 Cosentyx (secukinumab) vials
Cosentyx (secukinumab) is a human IgG1 monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine and inhibits its interaction with the IL-17 receptor. IL-17A is a naturally occurring cytokine involved in normal inflammatory and immune responses. Secukinumab inhibits the release of proinflammatory cytokines and chemokines.
Revised 2/23/24

MBP 134.0 Cresemba IV (isavuconazonium sulfate)
Cresemba IV (isavuconazonium sulfate) is an azole antifungal indicated for the treatment of invasive aspergillosis and for the treatment of invasive mucormycosis in patients 18 years of age and older.
Revised 8/18/23

MBP 182.0 Crysvita (burosumab-twza)
Crysvita (burosumab-twza) is an anti-FGF23 monoclonal antibody that binds to and inhibits the activity of fibroblast growth factor 23 (FGF23), thereby restoring renal phosphate reabsorption and increasing the serum concentration of 1,25 dihydroxy vitamin D.
Revised 11/15/22

MBP 115.0 Cyramza (ramucirumab)
Cyramza (ramucirumab) is a vascular endothelial growth factor receptor 2 (VEGFR2) antagonist that specifically binds VEGF Receptor 2 and blocks binding of VEGFR ligands.
Revised 6/6/23

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