Current medical benefit pharmaceutical policies
See the latest updates to our medical benefit pharmaceutical policies
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.
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.
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.
MBP 24.0 Aloxi (Palonosetron)
Aloxi (Palonosetron) is a 5-HT3 antagonist indicated for the prevention of chemotherapy induced nausea and vomiting.
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.
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.
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.
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.
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).
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