Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 198.0 Gamifant (emapalumab-lzsg)
Gamifant (emapalumab-lzsg) is an interferon gamma (IFNγ) blocking monoclonal antibody. IFNγ is hypersecreted in hemophagocytic lymphohistiocytosis (HLH); emapalumab binds to IFNγ and neutralizes it.
MBP 113.0 Gazyva (obinutuzumab)
Gazyva (obinutuzumab) is a monoclonal antibody that targets CD20 antigen that is expressed on the surface pf pre-B and mature B-cell lymphocytes.
MBP 211.0 Givlaari (givosiran)
Givlaari (givosiran) is a double-stranded small interfering RNA that causes degradation of aminolevulinate synthase 1 (ALAS1) mRNA in hepatocytes through RNA interference, reducing the elevated levels of liver ALAS1 mRNA. The reduction of ALAS1 mRNA decreases circulating levels of neurotoxic intermediates aminolevulinic acid (ALA) and porphobilinogen (PBG), which are factors associated with attacks and other disease manifestations of acute hepatic porphyria (AHP).
New Policy 5/19/20
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