Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 207.0 Xenleta IV (lefamulin)
Xenleta IV (lefamulin) is a pleuromutilin antibiotic that inhibits bacterial protein synthesis through interactions (hydrogen bonds, hydrophobic interactions, and Van der Waals forces) with the A- and P- sites of the peptidyl transferase center in domain V of the 23s ribosomal RNA of the 50S subunit. The binding pocket of the bacterial ribosome closes around the mutilin core for an induced fit that prevents correct positioning of transfer RNA.
MBP 284.0 Xenpozyme (olipudase alfa-rpcp)
Xenpozyme (olipudase alfa-rpcp) is an exogenous source of the enzyme acid sphingomyelinase (ASM). Olipudase alfa degrades sphingomyelin to ceramide and phosphocholine. Olipudase alfa is not expected to cross the blood-brain-barrier or address CNS manifestations of ASM deficiency.
New Policy 5/16/23
MBP 194.0 Xerava (eravacycline)
Xerava (eravacycline) is a fluorocycline antibiotic within the tetracycline class that binds to the 30S ribosomal subunit and prevents the incorporation of amino acid residues into elongating peptide chains, thereby, inhibiting bacterial protein synthesis.
MBP 89.0 Xgeva (denosumab)
Xgeva (denosumab) binds to RANKL, a transmembrane or soluble protein essential for the formation, function, and survival of osteoclasts, the cells responsible for bone resorption. Xgeva prevents RANKL from activating its receptor, RANK, on the surface of osteoclasts and their precursors. Increased osteoclast activity, stimulated by RANKL, is a mediator of bone pathology in solid tumors with osseous metastases.
MBP 80.0 Xiaflex (collagenase clostridium histolyticum)
Xiaflex (collagenase clostridium histolyticum) is a combination of bacterial collagenases isolated and purified from the fermentation of C. histolyticum bacteria; collagenase lyses collagen, leading to enzymatic disruption of contracted Dupuytren cord or Peyronie plaque (both comprised primarily of collagen).
MBP 110.0 Xofigo (radium Ra 223 dichloride)
Xofigo (radium Ra 223 dichloride) is an alpha particle-emitting radioactive therapeutic agent indicated for the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease
MBP 22.0 Xolair (Omalizumab)
Xolair (Omalizumab) is a recombinant humanized monoclonal antibody to immunoglobulin E (IgE). Currently, Xolair is available as a subcutaneous injection only.
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