Current medical benefit pharmaceutical policies

See the latest updates to our medical benefit pharmaceutical policies 

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A

MBP 36.0 Abraxane (paclitaxel protein bound particles)
Abraxane (paclitaxel protein bound particles) is a formulation of paclitaxel that is free of the solvent polyoxyethylated castor oil (Cremophor), which is thought to be the cause of the hypersensitivity reactions frequently encountered with standard paclitaxel.
Reviewed 9/20/16

MBP 76.0 Actemra IV (tocilizumab)
Actemra IV (tocilizumab) is a humanized interleukin-6 receptor –inhibiting monoclonal antibody. It competes for both membrane-bound and soluble forms of the human interleukin-6 receptor, thus inhibiting the binding of interleukin to its receptors and leading to the blockade of interleukin-6 signaling through the soluble and membrane-bound interleukin-6 receptors. Interleukin-6 is a pro- inflammatory cytokine commonly expressed in patients with rheumatoid arthritis.
Reviewed 9/28/16

MBP 7.0 Aldurazyme (laronidase)
Aldurazyme (laronidase) is used to treat mucopolysaccaridosis I (MPS I), an autosomal recessive disorder which causes a deficiency of alpha-L-iduronidase, an enzyme required to break down glycosaminoglycans.
Reviewed 1/30/17

MBP 24.0 Aloxi (Palonosetron)
Aloxi (Palonosetron) is a 5-HT3 antagonist indicated for the prevention of chemotherapy induced nausea and vomiting.
Revised 7/19/16

MBP 43.0 Alpha 1-Antitrypsin Inhibitor Therapy (Prolastin-C, Aralast, Zemaira, Glassia)
Alpha 1-antitrypsin (AAT) deficiency is an autosomal co-dominant genetic condition that may predispose people with the condition to emphysema in adult life, and liver disease in adults and children. In rare cases, alpha-1 antitrypsin deficiency also causes a skin condition characterized by hardened skin with painful lumps or patches.
Reviewed 1/30/17

MBP 149.0 Ameluz (aminolevulinic acid)
Ameluz (aminolevulinic acid) is a metabolic precursor of the photosensitizer protoporphyrin IX (PpIX). Photosensitization following local/topical application of aminolevulinic acid occurs through the metabolic conversion to PpIX. When exposed to light of appropriate wavelength and energy, accumulated PpIX produces a photodynamic reaction resulting in local cytotoxicity. Precancerous and cancerous cells exhibit a higher rate of porphyrin induction compared to normal cells.
New Policy 1/17/17

MBP 64.0 Arranon (nelarabine)
Arranon (nelarabine) is a pro-drug of the cytotoxic deoxyguanosine analogue, 9-β-D-arabinofuranosylguanine (ara-G). Nelarabine is demethylated by adenosine deaminase (ADA) to ara-G, mono-phosphorylated by deoxyguanosine kinase and deoxycytidine kinase, and subsequently converted to the active 5’-triphosphate, ara-GTP. Accumulation of ara-GTP in leukemic blasts allows for incorporation into deoxyribonucleic acid (DNA), leading to inhibition of DNA synthesis and cell death.
Reviewed 3/30/17

MBP 73.0 Arzerra (ofatumumab)
Arzerra (ofatumumab) is a monoclonal antibody that binds to a specific protein found on the surface of both normal and malignant B cells, making the cells more susceptible to immune system attack.
Revised 11/15/16

MBP 116.0 Aveed (testosterone undecanoate)
Aveed (testosterone undecanoate) injection is an androgen indicated for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone.
Reviewed 3/31/16

MBP 132.0 Avycaz (cetfazidime/avibactam)
Avycaz (cetfazidime/avibactam) is a combination cephalosporin/beta-lactamase inhibitor indicated in combination with metronidazole, for the treatment of complicated intra-abdominal infections (cIAI) and complicated urinary tract infections (cUTI).
Reviewed 5/27/16

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