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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.
Reviewed 1/1/21

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 5/18/21

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
Reviewed 8/26/21

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.
Reviewed 8/20/21

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 3/16/21

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 5/18/21

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.
Reviewed 9/15/1

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 1/19/21

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.
Reviewed 5/27/21

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.
Reviewed 9/15/21

MBP 75.0 Stelara (ustekinumab)
Stelara (ustekinumab) is a fully humanized immunoglobulin G1 monoclonal antibody that targets the p40 subunit of humal IL-12 and IL-23.
Revised 1/19/21

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.
Reviewed 1/19/21

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.
Reviewed 9/8/21

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.
Reviewed 8/20/21

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).
Reviewed 1/1/21

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.
Reviewed 1/1/21

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