Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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I

MBP 77.0 Ilaris (canakinumab)
Ilaris (canakinumab) is a fully humanized monoclonal antibody that rapidly and selectively blocks IL-1ß. Cryopyrin-associated periodic syndrome (CAPS) is caused by a single gene mutation that leads to overproduction of interleukin-1 beta (IL-1ß), which causes sustained inflammation and tissue damage.
Revised 5/16/17

MBP 129.0 Iluvien (fluocinolone acetonide)
Iluvien (fluocinolone acetonide) is an ophthalmic corticosteroid in the form of an intraocular implant indicated for the treatment of diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.
Reviewed 3/30/17

MBP 156.0 Imfinzi (durvalumab)
Imfinzi (durvalumab) is a human immunoglobulin G1 kappa (IgG1ҡ) monoclonal antibody. IgG1ҡ blocks the interaction between PD-L1 and PD-1/CD80, which stops the inhibition immune responses without inducing antibody dependent cell-mediated cytotoxicity.  PD-L1 blockade with durvalumab increased T-cell activation in vitro and decreased tumor size in mouse models.
New Policy 7/18/17 

MBP 136.0 Imlygic (talimogene laherparepvec)
Imlygic (talimogene laherparepvec) is a genetically modified oncolytic viral therapy indicated for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery.
Reviewed 10/28/16

MBP 5.0 Inflectra (infliximab-dyyb) or Remicade (infliximab)
Infliximab is a therapeutic agent that inhibits activity of tumor necrosis factor alpha (TNF-alpha), a biological response mediator of inflammation. TNF-alpha is a key inflammatory mediator in rheumatoid arthritis, Crohn’s disease and other autoimmune disorders. In these chronic conditions, overproduction of TNF-alpha leads to inflammation. Infliximab reduces inflammation by binding to and neutralizing TNF- alpha on the cell membrane and in the blood.
Revised 3/21/17

MBP 106.0 Injectable Antipsychotic Medications
Second generation (atypical) antipsychotics can be structurally classified as dibenzazepines, benzisoxazoles, benzisothiazolone, or quinolinone.24 ,31 As a group, they have diverse pharmacodynamic profiles differing considerably from the typical antipsychotics, but in general have an increased affinity for serotonin 5-HT2 receptors compared with D2 receptors.
Revised 7/18/17

MBP 4.0 Intravenous Immune Globulin (IVIG)
Immune Serum Globulins are used to provide passive immunity or to alter the immune response by increasing the recipients’ antibody titer and antigen-antibody reaction potential. IgG antibodies help to prevent or modify certain infectious diseases in susceptible individuals. Five major classes of immunoglobulin proteins exist in human serum and other body fluids (IgA, IgD, IgE, IgG, and IgM). Immune globulin is an antibody-containing solution obtained from the pooled plasma of pre-screened, presumably healthy blood donors.
Revised 3/21/17

MBP 78.0 Istodax (romidepsin)
Istodax (romidepsin) is an injectable histone deacetylase (HDAC) inhibitor. HDACs catalyze the removal of acetyl groups from acetylated lysine residues in histones, resulting in the modulation of gene expression. Romidepsin induces cell cycle arrest and apoptosis of some cancer cell lines.
Reviewed 10/26/16

MBP 63.0 Ixempra (ixabepilone)
Ixempra (ixabepilone) is a semi-synthetic analog of epothilone B. Ixabepilone binds directly to β-tubulin subunits on microtubules, leading to suppression of microtubule dynamics. Ixabepilone suppresses the dynamic instability of αβ-II and αβ-III microtubules and blocks cells in the mitotic phase of the cell division cycle, leading to cell death.
Reviewed 3/30/17

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