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:

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

D

MBP 46.0 Dacogen (decitabine)
Dacogen (decitabine) is an antineoplastic analog of 2-deoxycytidine; approved by the FDA for treatment of myelodysplastic syndrome.
Reviewed 1/31/17

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.
Revised 11/28/16

MBP 139.0 Darzalex (daratumumab)
Darzalex (daratumumab) is an IgG1Κ human monoclonal antibody directed against CD38. Darzalex is indicated for the treatment of patients with multiple myeloma who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent
Revised 1/17/17

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