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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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H

MBP 88.0 Halaven (eribulin mesylate)
Halaven (eribulin) is a nontaxane microtubule dynamics inhibitor that inhibits the growth phase of microtubules without affecting the shortening phase, and sequesters tubulin into nonproductive aggregates. Eribulin exerts its effects via a tubulin-based antimitotic mechanism leading to G2/M cell-cycle block, disruption of mitotic spindles, and, ultimately, apoptotic cell death after prolonged mitotic blockage
Revised 8/14/23

MBP 286.0 Hemgenix (etranacogene dezaparvovec-drlb)
Hemgenix (etranacogene dezaparvovec-drlb) is an adeno-associated virus serotype 5 (AAV5) vector-based gene therapy. It is a nonreplicating recombinant AAV5 containing a codon-optimized DNA sequence of the gain-of-function Padua variant of human factor IX (variant R338L), under control of a liver-specific promotor 1 (LP1). Etranacogene dezaparvovec administration results in cell transduction and increases circulating factor IX activity in patients with hemophilia B.
Revised 9/11/23

MBP 179.0 Hemlibra (emicizumab-kxwh)
Hemlibra (emicizumab-kxwh) is a humanized monoclonal modified immunoglobulin G4 (IgG4) antibody with a bispecific factor IXa- and factor X-directed antibody, bridges activated factor IX and factor X to restore the function of missing activated factor VIII that is needed for effective hemostasis. Emicizumab-kxwh has no structural relationship or sequence homology to FVIII and, therefore, does not induce or enhance the development of direct inhibitors to FVIII.

Hemlibra is indicated for routine prophylaxis to prevent or reduce the frequency of bleeding episodes in patients with hemophilia A (congenital factor VIII deficiency) with factor VIII inhibitors.
Revised 1/8/24

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