Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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Y

MBP 91.0 Yervoy (Ipilimumab)
Yervoy (Ipilimumab) is a recombinant, human monoclonal antibody that binds to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). Ipilimumab is an IgG1 kappa immunoglobulin with an approximate molecular weight of 148 kDa. Ipilimumab binds to CTLA-4 and blocks the interaction of CTLA-4 with its ligands, CD80/CD86. Blockade of CTLA-4 has been shown to augment T-cell activation and proliferation. The mechanism of action of ipilimumab’s effect in patients with melanoma is indirect, possibly through T-cell mediated anti-tumor immune responses.
Reviewed 2/28/17

MBP 137.0 Yondelis (trabectedin)
Yondelis (trabectedin) is an alkylating drug indicated for the treatment of patients with unresectable or metastatic liposarcoma or leiomyosarcoma who received a prior anthracycline-containing regimen.
Reviewed 10/28/16

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