Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

Choose a letter to view policies by first letter:

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

C

MBP 60.0 Cerezyme (imiglucerase)
Cerezyme (imiglucerase) is an analogue of the human enzyme ß-glucocerebrosidase, produced by recombinant DNA technology.
Revised 4/28/17

MBP 74.0 Cimzia (certolizumab pegol)
Cimzia (certolizumab pegol) is a tumor necrosis factor alpha (TNFα) inhibitor PEGylated humanized Fab fragment of an anti-tumor necrosis factor – α monoclonal antibody. It binds with high affinity to both membrane-bound and soluble TNFα and demonstrated neutralizing of cytokines.
Reviewed 9/28/16

MBP 145.0 Cinqair (reslizumab)
Cinqair (reslizumab) is an interleukin-5 antagonist (IgG4 kappa). IL-5 is the major cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils (a cell type associated with inflammation and an important component in the pathogenesis of asthma). Reslizumab, by inhibiting IL-5 signaling, reduces the production and survival of eosinophils; however, the mechanism of reslizumab action in asthma has not been definitively established. Nucala is indicated as add-on maintenance therapy for patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.
New Policy 9/20/16

MBP 85.0 Cinryze (C1 esterase inhibitor, human)
Cinryze (C1 esterase inhibitor, human) is indicated for routine prophylaxis against angioedema attacks in adult and adolescent patients with Hereditary Angioedema.
Reviewed 3/31/16

MBP 38.0 Clolar (clofarabine)
Clolar (clofarabine) is a purine nucleoside antimetabolite antineoplastic agent.
Reviewed 1/31/17

MBP 131.0 Cosentyx (secukinumab) vials
Cosentyx (secukinumab) is a human IgG1 monoclonal antibody (immunomodulator) indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.
Revised 7/19/16

MBP 134.0 Cresemba IV (isavuconazonium sulfate)
Cresemba IV (isavuconazonium sulfate) is an azole antifungal indicated for the treatment of invasive aspergillosis and for the treatment of invasive mucormycosis in patients 18 years of age and older.
Reviewed 9/14/16

MBP 115.0 Cyramza (ramucirumab)
Cyramza (ramucirumab) is a vascular endothelial growth factor receptor 2 (VEGFR2) antagonist that specifically binds VEGF Receptor 2 and blocks binding of VEGFR ligands.
Reviewed 5/27/16

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