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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:



MBP 99.0 Sandostatin LAR (octreotide acetate)
Sandostatin LAR (Octreotide acetate) is the acetate salt of a cyclic octapeptide with pharmacologic properties mimicking those of the natural hormone somatostatin. Sandostatin® LAR Depot is a long-acting dosage form consisting of microspheres of the biodegradable glucose star polymer, D,L-lactic and glycolic acids copolymer, containing octreotide.
Revised 12/6/23

MBP 249.0 Saphnelo (anifrolumab-fnia)
Anifrolumab is an IgG1-kappa monoclonal antibody that blocks the biologic activity of type 1 interferon receptors (IFNAR); elevated IFNAR plays a role in the pathogenesis of systemic lupus erythematosus. This reduces inflammatory and immunological processes.
Reviewed 1/15/24

MBP 213.0 Sarclisa (isatuximab-irfc)
Sarclisa (isatuximab-irfc) is a CD38-directed monoclonal antibody that binds to CD38 expressed on the surface of hematopoietic and tumor cells (including multiple myeloma cells).  After binding, Sarclisa induces apoptosis the cells and activates immune effector mechanisms via antibody-dependent cell-mediated cytotoxicity (ADCC), antibody-dependent cellular phagocytosis (ADCP), and complement dependent cytotoxicity (CDC).  The combination of Sarclisa and pomalidomide enhanced ADCC activity and direct tumor cell killing compared to that of Sarclisa alone in vitro, and enhanced antitumor activity compared to the activity of Sarclisa or pomalidomide alone in human multiple myeloma xenograft model.
Revised 3/31/23

MBP 220.0 Scenesse (afamelanotide)
Scenesse (afamelanotide) is a synthetic Alpha-Melanocyte Stimulating Hormone Analog. Afamelanotide is a melanocortin receptor agonist that binds predominantly to MC1-R; increases production of eumelanin in the skin independently of exposure to sunlight or artificial UV light sources
Revised 9/27/22

MBP 133.0 Signifor LAR (pasireotide LAR)
Signifor LAR (pasireotide LAR) is a cyclohexapeptide somatostatin analogue approved for the treatment of patients with acromegaly who have had an inadequate response to surgery and/or for whom surgery is not an option. Signifor LAR is also approved for the treatment of patients with Cushing’s disease for whom pituitary surgery is not an option or has not been curative. 
Revised 8/18/23

MBP 112.0 Simponi Aria (golimumab)
Simponi Aria (golimumab) is a tumor necrosis factor (TNF) blocker indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis in combination with methotrexate.
Revised 3/13/23

MBP 181.0 Site of Care
Specific intravenous and injectable drugs must meet applicable medical necessity criteria for coverage.  If these criteria are met, this coverage policy will be used to determine the medical necessity of administration in the hospital based outpatient setting.  If medical necessity criteria for administration in the hospital based outpatient setting are not met, an alternative less intensive site of care facility should be utilized.   
Revised 7/15/23

MBP 122.0 Sivextro (tedizolid phosphate) IV
Sivextro (tedizolid phosphate) IV is an oxazolidinone that works by binding to the 23S ribosomal RNA of the 50S subunit, thereby preventing the formation of the 70S initiation complex and inhibiting protein synthesis.
Revised 9/13/22

MBP 54.0 Soliris (eculizumab)
Soliris (eculizumab) is approved by the FDA for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). Soliris works by blocking a part of the immune system called complement. By blocking complement, Soliris reduces the destruction of red blood cells and improves the symptoms of PNH.
Revised 8/25/23

MBP 267.0 Skyrizi IV (risankizumab intravenous)
Risankizumab is a human IgG1 monoclonal antibody which selectively binds to the p19 subunit of interleukin (IL)-23, thereby inhibiting its interaction with the IL-23 receptor, resulting in inhibition of the release of proinflammatory cytokines and chemokines.
Revised 10/16/23

MBP 282.0 Skysona (elivaldogene autotemcel)
Skysona (elivaldogene autotemcel) is a gene therapy consisting of autologous CD34+ hematopoietic cells transduced with the Lenti-D lentiviral vector to add functional copies of the ABCD1 cDNA into the hematopoietic stem cells. After elivaldogene autotemcel infusion, transduced CD34+ hematopoietic stem cells engraft in the bone marrow and differentiate to produce various cell types, including monocytes (CD14+) capable of producing functional ALDP. Functional ALDP participates in the local degradation of very long chain fatty acids, which slows or possibly prevents further demyelination and inflammation.
New Policy 5/16/23

MBP 274.0 Spevigo (spesolimab-sbzo)
Spevigo (spesolimab-sbzo) is a humanized monoclonal antibody that binds to interleukin-36 (IL36) receptor and prevents binding of endogenous IL36 which prevents activation of proinflammatory and profibrotic pathways by endogenous IL36. The precise role of reduced IL36 receptor activity in generalized pustular psoriasis (GPP) is unknown.
Reviewed 2/14/24

MBP 151.0 Spinraza (nusinersen)
Spinraza (nusinersen) treats spinal muscular atrophy caused by mutations in chromosome 5q that lead to survival motor neuron (SMN) protein deficiency by binding to a specific sequence in the intron downstream of exon 7 of the SMN2 messenger ribonucleic acid (mRNA) transcript and increase production of full-length SMN protein.
Revised 5/9/23

MBP 195.0 Spravato (esketamine)
Spravato (esketamine) is a nonselective, noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. The mechanism by which it exerts its antidepressant effect is unknown. The major circulating metabolite noresketamine demonstrated activity at the same receptor with less affinity.
Revised 9/12/23

MBP 75.0 Stelara (ustekinumab)
Stelara (ustekinumab) is a fully humanized immunoglobulin G1 monoclonal antibody that targets the p40 subunit of human IL-12 and IL-23.
Revised 12/31/23

MBP 67.0 Supprelin LA (histrelin acetate implant)
Supprelin LA (histrelin acetate implant) is a gonadotropin releasing hormone (GnRH) agonist. The primary goal of all GnRH agonist therapy is to maintain constant levels of the drug in order to have continuous desensitization of GnRH receptors and thus complete hormonal inhibition.
Revised 1/8/24

MBP 150.0 Sustol (granisetron ER)
Sustol (granisetron ER) is a selective 5-hydroxytryptamine3 receptor (5-HT3) antagonist with minimal affinity for other serotonin receptors, alpha- or beta-adrenoreceptors, dopamine2, or histamine1 receptors. 5-HT3 receptors are located peripherally on the vagal nerve terminals and centrally in the chemoreceptor trigger zone. During chemotherapy that induces vomiting, serotonin is released and stimulates 5-HT3, which evokes vagal afferent discharge, inducing vomiting. Granisetron blocks serotonin stimulation and subsequent vomiting after emetogenic stimuli.
Revised 9/7/23

MBP 252.0 Susvimo (ranibizumab implant)
Ranibizumab is a recombinant humanized monoclonal antibody fragment which binds to and inhibits human vascular endothelial growth factor A (VEGF-A). Ranibizumab inhibits VEGF from binding to its receptors and thereby suppressing neovascularization and slowing vision loss.
Revised 5/11/23

MBP 278.0 Syfovre (pegcetacoplan)
Syfovre (pegcetacoplan) binds to complement protein C3 and its activation fragment C3b with high affinity, regulating the cleavage of C3 and the generation of downstream effectors of complement activation.
New Policy 4/25/23

MBP 120.0 Sylvant (siltuximab)
Sylvant (siltuximab) is an interleukin-6 (IL-6) antagonist indicated for the treatment of patients with multicentric Castleman disease (MCD) who are human immunodeficiency virus (HIV) negative and human herpesvirus-8 (HHV-8) negative.
Revised 8/18/23

MBP 2.0 Synagis (palivizumab)
Palivizumab is a humanized monoclonal antibody (IgG1k) produced by recombinant DNA technology used as a prophylaxis against lower respiratory tract infection with respiratory syncytial virus (RSV).
Revised 9/19/23

MBP 102.0 Synribo (omacetaxine mepesuccinate)
Synribo (omacetaxine mepesuccinate) binds to the A-site cleft in the peptidyl-transferase center of the large ribosomal subunit from a strain of archaeabacteria. In vitro, omacetaxine mepesuccinate reduced protein levels of the Bcr-Abl oncoprotein and Mcl-1, an anti-apoptotic Bcl-2 family member. Omacetaxine mepesuccinate showed activity in mouse models of wild-type and T315I mutated Bcr-Abl CML.       
Revised 12/18/23

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