Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 121.0 Dalvance (dalbavancin)
Dalvance (dalbavancin), a semisynthetic lipoglycopeptide, interferes with cell wall synthesis by binding to the D-alanyl-D-alanine terminus of the stem pentapeptide in nascent cell wall peptidoglycan, thus preventing cross-linking.
MBP 227.0 Danyelza (naxitamab-gqgk)
Danyelza (naxitamab-gqgk) is an anti-GD2 monoclonal antibody that binds to the glycolipid disialoganglioside (GD2), which is highly expressed in neuroblastoma, and other cells of neuroectodermal origin, including the central nervous system and peripheral nerves. By binding to cell surface GD2, naxitamab induces cell lysis (of GD2-expressing cells) through antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC).
New Policy 2/26/21
MBP 139.0 Darzalex (daratumumab)
Darzalex (daratumumab) is an IgG1κ human monoclonal antibody directed against CD38. CD38 is a cell surface glycoprotein which is highly expressed on myeloma cells, yet is expressed at low levels on normal lymphoid and myeloid cells (Lokhorst 2015). By binding to CD38, daratumumab inhibits the growth of CD38 expressing tumor cells by inducing apoptosis directly through Fc mediated cross linking as well as by immune-mediated tumor cell lysis through complement dependent cytotoxicity, antibody dependent cell mediated cytotoxicity, and antibody dependent cellular phagocytosis.
MBP 230.0 Darzalex Faspro (daratumumab-hyaluronidase)
Darzalex Faspro (daratumumab/hyaluronidase) is an Anti-CD38 monoclonal antibody combination therapy. Daratumumab is an IgG1κ human monoclonal antibody directed against CD38. CD38 is a cell surface glycoprotein which is highly expressed on myeloma cells. By binding to CD38, daratumumab inhibits the growth of CD38-expressing tumor cells by inducing apoptosis directly through Fc mediated cross linking as well as by immune-mediated tumor cell lysis through complement dependent cytotoxicity, antibody dependent cell mediated cytotoxicity, and antibody dependent cellular phagocytosis. Hyaluronidase increases permeability of the subcutaneous tissue by depolymerizing hyaluronan. At the recommended dose, hyaluronidase acts locally and the effects are reversible; permeability of subcutaneous tissue is restored within 24 to 48 hours.
MBP 255.0 Dextenza (dexamethasone ophthalmic (intracanalicular) insert)
Dextenza is an intracanalicular insert of dexamethasone, a corticosteroid, which has been shown to suppress inflammation by inhibiting multiple inflammatory cytokines resulting in decreased edema, fibrin deposition, capillary leakage and migration of inflammatory cells.
New Policy 3/15/22
MBP 243.0 Durysta (bimatoprost intraocular implant)
Bimatoprost is a synthetic prostaglandin analog that decreases intraocular pressure by increasing the outflow of aqueous humor.
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