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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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MBP 101.0 Zaltrap (ziv-aflibercept)
Zaltrap (ziv-aflibercept) acts as a soluble receptor that binds to human VEGF-A, to human VEGF-B, and to human PlGF. By binding to these endogenous ligands, ziv-aflibercept can inhibit the binding and activation of their cognate receptors. This inhibition can result in decreased neovascularization and decreased vascular permeability.
Revised 12/6/23

MBP 187.0 Zemdri (plazomicin)
Zemdri (plazomicin) is an aminoglycoside, which acts by binding to bacterial 30S ribosomal subunit, inhibiting protein synthesis.
Revised 9/16/22

MBP 222.0 Zepzelca (lurbinectedin)
Zepzelca (lurbinectedin) is an alkylating agent and a selective inhibitor of oncogenic transcription which binds preferentially to guanine residues in the minor groove of DNA; this forms adducts and bends the DNA helix towards the major groove. Adduct formation affects the activities of DNA binding proteins, including some transcription factors and DNA repair pathways. Inhibition of oncogenic transcription results in tumor cell apoptosis.
Revised 9/15/22

MBP 205.0 Zerbaxa (ceftolozane/tazobactam)
Zerbaxa (ceftolozane/tazobactam) is a cephalosporin combination. Ceftolozane inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs); which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Ceftolozane is an inhibitor of PBPs of Pseudomonas aeruginosa (eg, PBP1b, PBP1c, and PBP3) and Escherichia coli (eg, PBP3). Tazobactam irreversibly inhibits some beta-lactamases (eg, certain penicillinases and cephalosporinases), and can covalently bind to some plasmid-mediated and chromosomal bacterial beta-lactamases.
Revised 8/22/23

MBP 15.0 Zevalin (Ibritumomab tiuxetan (IDEC Y2B8))
ZevalinTM (ibritumomab tiuxetan) is the immunoconjugate resulting from a stable thiourea covalent bond between the monoclonal antibody ibritumomab and the linker-chelator tiuxetan. Zevalin binds specifically to the CD20 antigen (human B-lymphocyte-restricted differentiation antigen, Bp35) and prevents shedding from the cell surface and internalization upon antibody binding
Revised 1/15/24

MBP 178.0 Zilretta (triamcinolone acetonide ER injection)
Zilretta (triamcinolone acetonide ER injection) is an extended-release intra-articular injection of triamcinolone that is indicated for the management of osteoarthritis pain of the knee. It is a long acting corticosteroid with minimal sodium-retaining potential. Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability.
Revised 12/6/23

MBP 153.0 Zinplava (bezlotoxumab)
Zinplava (bezlotoxumab) is a human IgG1 monoclonal antibody that binds to C. difficile toxin B and neutralizes it to prevent its toxic effects; bezlotoxumab does not bind to C. difficile toxin A.
Revised 1/8/24

MBP 199.0 Zolgensma (onasemnogene abeparvovec-xioi)
Zolgensma (onasemnogene abeparvovec-xioi) is a recombinant adeno-associated virus vector-based gene therapy that delivers a normal copy of the gene encoding human survival motor neuron (SMN) protein. Zolgensma is used to treat pediatric patients less than 2 years of age with Spinal Muscular Atrophy (SMA). Also indicated for SMA is Spinraza (nusinersen), a survival motor neuron-2 (SMN2)-directed antisense Oligonucleotide that was shown to increase exon 7 inclusion in SMN2 messenger ribonucleic acid (mRNA) transcripts and production of full-length SMN protein.
Revised 7/26/23

MBP 201.0 Zulresso (brexanolone)
Zulresso (brexanolone) is a gamma-aminobutyric acid (GABA) A receptor positive modulator indicated for the treatment of postpartum depression in adults. The exact mechanism of action is not fully understood but is thought to be related to positive allosteric modulation of GABA-A receptors.
Revised 9/20/22

MBP 237.0 Zynlonta (loncastuximab tesirine-lpyl)
Zynlonta is an antibody drug conjugate that contains a humanized IgG1 monoclonal antibody directed at CD19, conjugated to a pyrrolobenzodiazepine dimer cytotoxic alkylating agent (SG3199) via a protease cleavable linker (the linker with SG3199 attached is the small molecule cytotoxin, SG3249 [tesirine]). The antibody component binds to CD19 (a transmembrane protein expressed on B-cell surfaces). After binding, Zynlonta is internalized and releases SG3199 via proteolytic cleavage. SG3199 then binds to the DNA minor groove and forms highly cytotoxic DNA inter-strand crosslinks and induces cell death.
Revised 6/27/22

MBP 276.0 Zynteglo (betibeglogene autotemcel)
Zynteglo (betibeglogene autotemcel) is a gene therapy consisting of autologous CD34+ hematopoietic cells transduced with the BB305 lentiviral vector to add functional copies of a modified β-globin gene (Locatelli 2022). After betibeglogene autotemcel infusion, transduced CD34+ cells engraft in the bone marrow and differentiate to produce RBCs containing a modified β-globin protein (βA-T87Q-globin) to combine with α-globin and produce functional adult Hb. βA-T87Q-globin expression corrects the β/α-globin imbalance in erythroid cells of patients with β-thalassemia to increase functional adult HbA and total Hb to normal levels and eliminate dependence on RBC transfusions.
New Policy 3/21/23

MBP 285.0 Zynyz (retifanlimab-dlwr)
Zynyz (retifanlimab-dlwr) is a humanized IgG4 monoclonal antibody which is a programmed death receptor-1 (PD-1) blocking antibody. Retifanlimab binds to the PD-1 receptor, blocking interaction with its ligands, PD-L1 and PD-L2, and potentiating T-cell activity. PD-L1 and PD-L2 binding to the PD-1 receptor on T-cells inhibits T-cell proliferation and cytokine production. Upregulation of PD-1 ligands occurs in some tumors; therefore, signaling through this pathway can contribute to inhibition of active T-cell immune surveillance of tumors.
New Policy 5/16/23

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