Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 196.0 Ultomiris (Ravulizumab-cwvz)
Ultomiris (Ravulizumab-cwvz) is a humanized monoclonal antibody which is a terminal complement inhibitor that specifically binds to the complement protein C5 (with high affinity), inhibiting its cleavage to C5a (the proinflammatory anaphylatoxin) and C5b (the initiating subunit of the terminal complement complex [C5b-9]) and preventing generation of the terminal complement complex C5b9. The C5 inhibition of complement-mediated hemolysis achieved by ravulizumab in patients with paroxysmal nocturnal hemoglobinuria is immediate, thorough, and sustained. Additionally, ravulizumab inhibits terminal complement-mediated thrombotic microangiopathy (TMA) in patients with atypical Hemolytic Uremic Syndrome.
MBP 135.0 Unituxin (dinutuximab)
Unituxin (dinutuximab) is an Anti-GD2, monoclonal antibody, indicated, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multiagent, multimodality therapy.
MBP 225.0 Uplizna (inebilizumab-cdon)
Uplizna (inebilizumab-cdon) is an anti-CD19 monoclonal antibody directed against pre-B and mature B-cell lymphocytes, which express the cell surface antigen CD19. Following binding to CD19, inebilizumab causes antibody-dependent cellular cytolysis.
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