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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 277.0 Elahere (mirvetuximab soravtansine-gynx)
Elahere (mirvetuximab soravtansine-gynx) is an antibody-drug conjugate which consists of 3 components, a folate receptor alpha (FRα)-directed monoclonal antibody (IgG1 subtype), a small molecule anti-tubulin agent DM4 (a maytansine derivative), and a linker that covalently attaches DM4 to the mirvetuximab antibody. The antibody portion is a chimeric IgG1 directed against folate receptor alpha (FRα); DM4 is a microtubule inhibitor attached to the antibody via a cleavable linker. Upon binding to FRα, mirvetuximab soravtansine is internalized and then intracellularly releases DM4 via proteolytic cleavage. DM4 disrupts the microtubule network within the cell, resulting in cell cycle arrest and apoptosis.
New Policy 4/25/23

MBP 44.0 Elaprase (idursulfase)
Elaprase (idursulfase) is a formulation of idursulfase, a purified form of human iduronate-2- sulfatase, a lysosomal enzyme. It is approved by the FDA for treatment of mucopolysaccharidosis II (MPS II) (Hunter’s syndrome).
Revised 8/9/23

MBP 100.0 Elelyso (taliglucerase alfa)
Elelyso (taliglucerase alfa) is a hydrolytic lysosomal glucocerebroside-specific enzyme indicated for long-term enzyme replacement therapy (ERT) for adults with a confirmed diagnosis of Type 1 Gaucher disease.
Revised 1/8/24

MBP 307.0 Elevidys (delandistrogene moxeparvovec-rokl)
Delandistrogene moxeparvovec is a nonreplicating, recombinant adeno-associated virus serotype rh74 vector-based gene therapy that delivers a normal copy of the gene encoding a micro-dystrophin protein expressed in normal muscle cells.
New Policy 12/22/23

MBP 289.0 Elfabrio (pegunigalsidase alfa-iwxj)
Elfabrio (pegunigalsidase alfa-iwxj) is a recombinant form of the enzyme alpha-galactosidase-A, which catalyzes the hydrolysis of globotriaosylceramide (Gb-3), cleaving a terminal galactose residue from the molecule. Accumulation of globotriaosylceramide (Gb-3) may occur within the tissues of patients with Fabry disease. Pegunigalsidase alfa is internalized and transported into lysosomes exerting enzymatic activity and reducing cellular levels of Gb-3.
New Policy 7/18/23

MBP 29.0 Elitek (rasburicase)
Elitek (rasburicase) is an intravenously administered recombinant urate-oxidase enzyme, which converts uric acid to allantoin (an inactive and soluble metabolite of uric acid); it does not inhibit the formation of uric acid.
Revised 7/24/23

MBP 301.0 Elrexfio (elranatamab-bcmm)
Elranatamab is a bispecific, humanized, IgG2-alanine kappa, B-cell maturation antigen (BCMA)-directed T-cell engaging antibody that binds BCMA (present on plasma cells, plasmablasts, and multiple myeloma cells) and CD3 (present on T cells). Upon binding to both BCMA and CD3, lysis of BCMA-expressing malignant plasma cells by elranatamab occurs via T-cell activation and the release of proinflammatory cytokines.
New Policy 10/25/23

MBP 197.0 Elzonris (Tagraxofusp-erzs)
Elzonris (Tagraxofusp-erzs) is a CD123-directed fusion protein which is composed of human interleukin-3 (IL-3) and truncated diphtheria toxin (DT). After binding to CD123, tagraxofusp is internalized, leading to inhibition of protein synthesis and cell death
Revised 1/15/24

MBP 104.0 Emend IV (fosaprepitant)
Emend IV (fosaprepitant) is a substance P/neurokinin (NK1) receptor antagonist indicated for the prevention of acute and delayed nausea and vomiting associated with moderately-and highly-emetogenic chemotherapy (in combination with other antiemetics). 
Revised 10/10/23

MBP 245.0 Empaveli (pegcetacoplan)
Pegcetacoplan is a pegylated pentadecapeptide that targets complement C3. In binding to complement protein C3 (and its activation fragment C3b), pegcetacoplan regulates the cleavage of C3 and the generation of downstream effectors of complement activation. Pegcetacoplan acts in the complement cascade that controls both C3b-mediated extravascular hemolysis and terminal complement-mediated intravascular hemolysis.
Revised 10/16/23

MBP 140.0 Empliciti (elotuzumab)
Empliciti (elotuzumab) is a humanized immunoglobulin G1 (IgG1) immunostimulatory monoclonal antibody directed against signaling lymphocytic activation molecule family member 7 (SLAMF7, also called CS1 [cell surface glycoprotein CD2 subset 1]). Empliciti is indicated in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma who have received one to three prior therapies.
Revised 8/18/23

MBP 208.0 Enhertu (fam-trastuzumab deruxtecan-nxki)
Enhertu (fam-trastuzumab deruxtecan-nxki) is a HER2-directed antibody and topoisomerase inhibitor conjugate that binds to HER2 on tumor cells, undergoes internalization and intracellular linker cleavage by lysosomal enzymes, and upon release, causes DNA damage and apoptotic cell death.
Revised 12/19/23

MBP 264.0 Enjaymo (sutimlimab-jome)
Enjaymo (sutimlimab-jome) is a humanized immunoglobulin G (IgG4) monoclonal antibody which targets and inhibits the classical complement pathway by specifically binding to the complement protein component 1, s subcomponent (C1s), which is a serine protease that cleaves C4. Inhibition of the classical complement pathway at the C1s level prevents deposition of complement opsonins on red blood cell (RBC) surfaces, resulting in inhibition of hemolysis in cold agglutinin disease. Sutimlimab does not inhibit the lectin and alternative pathways.
Revised 7/18/23

MBP 118.0 Entyvio (vedolizumab)
Entyvio (vedolizumab) is a humanized monoclonal antibody indicated for the treatment of Crohn’s Disease and Ulcerative Colitis.
Revised 5/11/23

MBP 290.0 Epkinly (epcoritamab-bysp)
Epkinly (epcoritamab-bysp) is a bispecific T-cell engaging antibody that targets CD3 and CD20. Epcoritamab binds to the CD3 receptor expressed on the surface of T-cells and CD20 expressed on the surface of lymphoma cells and healthy B-lineage cells. Epcoritamab activates T-cells resulting in the release of proinflammatory cytokines and induces B-cell lysis.
Revised 8/29/23

MBP 53.0 Eraxis (anidulafungin)
Eraxis (anidulafungin) is an echinocandin antifungal agent that results in the inhibition of β-1,3-D-glucan synthase, an essential component of fungal cell walls.
Revised 1/15/24

MBP 95.0 Erwinaze (aspiraginase)
Erwinaze (aspiraginase) is an amino acid that is essential for cell growth; it is produced by most, but not all cells. Mutated cancer cells in acute lymphoblastic leukemia (ALL) rely on asparagine circulating in the blood for growth. L-asparaginases are a group of enzymes that lower circulating asparagine levels in the blood, thereby depriving the mutated blood cells of asparagine and inhibiting their growth.
Revised 12/19/22

MBP 49.0 Erythropoietin and Darbepoetin Therapy
Erythropoietin therapy (e.g., EPO, Epogen [epoetin alfa], Retacrit [epoetin alfa-epbx], Procrit [epoetin beta]) and darbepoetin alfa therapy (Aranesp) is used to stimulate red blood cell production in the bone marrow, with the goal of correcting anemia, minimizing the need for transfusion requirements, and improving the anemic insured individual’s quality of life. 
Revised 10/26/23

MBP 202.0 Evenity (romosozumab-aqqg)
Evenity (romosozumab-aqqg) is a sclerostin inhibitor monoclonal antibody that inhibits sclerostin, a regulatory factor in bone metabolism that inhibits Wnt/Beta-catenin signaling pathway regulating bone growth; romosozumab increases bone formation and to a lesser extent, decreases bone resorption.
Reviewed 8/22/23

MBP 242.0 Evkeeza (evinacumab-dgnb)
Evinacumab-dgnb is a recombinant human monoclonal antibody that binds to and inhibits angiopoietin-like protein 3 (ANGPTL3). ANGPTL3 inhibits lipoprotein lipase (LPL) and endothelial lipase (EL). ANGPTL3 inhibition by evinacumab results in increased lipid metabolism, leading to decreased low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), and triglycerides (TG). Evinacumab-dgnb reduces LDL-C independent of the presence of LDL receptor by promoting very low-density lipoprotein processing and clearance upstream of LDL formation. Evinacumab-dgnb blockade of ANGPTL3 lowers TG and HDL-C by rescuing LPL and EL activities, respectively.
Revised 8/25/23

MBP 148.0 Exondys 51 (eteplirsen)
Exondys 51 (eteplirsen) binds to exon 51 of dystrophin pre-messenger RNA (mRNA), resulting in exclusion of this exon during mRNA processing. Exon skipping allows for production of an internally truncated dystrophin protein. Eteplirsen is indicated in the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping.

This indication is approved under accelerated approval based on an increase in dystrophin in skeletal muscle observed in some patients treated with Exondys 51. A clinical benefit of Exondys 51 has not been established. Continued approval for this indication may be contingent upon verification of a clinical benefit in confirmatory trials.
Revised 1/2/24

MBP 94.0 Eylea/Eylea HD (aflibercept)
Eylea (aflibercept) is a recombinant fusion protein that acts as a decoy receptor for vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PLGF). Aflibercept binds to VEGF-A and PLGF and inhibits binding and activating of endothelial cell receptors, thereby suppressing neovascularization and slowing vision loss.
Revised 12/31/23

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