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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 7/31/17

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.
Revised 9/19/17

MBP 166.0 Adcetris (brentuximab vedotin)
Adcetris (brentuximab vedotin) is an antibody drug conjugate (ADC) directed at CD30 consisting of 3 components: 1) a CD30-specific chimeric IgG1 antibody cAC10; 2) a microtubule-disrupting agent, monomethylauristatin E (MMAE); and 3) a protease cleavable dipeptide linker (which covalently conjugates MMAE to cAC10). The conjugate binds to cells which express CD30, and forms a complex which is internalized within the cell and releases MMAE. MMAE binds to the tubules and disrupts the cellular microtubule network, inducing cell cycle arrest (G2/M phase) and apoptosis.
New Policy 2/1/18

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 10/31/17

MBP 161.0 Aliqopa (copanlisib)
Aliqopa (copanlisib) inhibits phosphatidylinositol 3-kinase (PI3K), primarily the P13K-alpha and P13K-delta isoforms which are expressed in malignant B-cells. Copanlisib induces tumor cell death through apoptosis and inhibition of proliferation of primary malignant B cell lines. In addition, copanlisib inhibits several signaling pathways, including B-cell receptor signaling, CXCR12 mediated chemotaxis of malignant B cells, and NFκB signaling in lymphoma cell lines.
New Policy 11/21/17

MBP 24.0 Aloxi (Palonosetron)
Aloxi (Palonosetron) is a 5-HT3 antagonist indicated for the prevention of chemotherapy induced nausea and vomiting.
Revised 2/27/18

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 10/31/17

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.
Revised 10/31/17

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.
Reviewed 10/31/17

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.
Revised 6/5/17

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 5/16/17

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