Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 266.0 Jelmyto (mitomycin ureteral gel)
Mitomycin alkylates DNA to produce DNA cross-linking (primarily with guanine and cytosine pairs) and inhibits DNA and RNA synthesis. Mitomycin is not cell cycle specific but has its maximum effect against cells in late G and early S phase. Following instillation into the pyelocalyceal system, mitomycin (ureteral gel) forms a semisolid gel that dissolves from normal kidney urine flow, releasing mitomycin.
New Policy 9/20/22
MBP 236.0 Jemperli (dostarlimab-gxly)
Jemperli is an anti-PD-1 humanized IgG4 monoclonal antibody which inhibits programmed cell death-1 (PD-1) activity by binding to the PD-1 receptor on T-cells to block PD-1 ligands (PD-L1 and PD-L2) from binding. Blocking the PD-1 pathway inhibits the negative immune regulation caused by PD-1 receptor signaling.
MBP 82.0 Jevtana (cabazitaxel)
Jevtana (cabazitaxel) is a microtubule inhibitor indicated in combination with prednisone for treatment of patients with hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing treatment regimen.
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