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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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MBP 44.0 Elaprase (idursulfase)
Elaprase (idursulfase) is a formulation of idursulfase, a purified form of human iduronate-2- sulfatase, a lysosomal enzyme. It is approved by the FDA for treatment of mucopolysaccharidosis II (MPS II) (Hunter’s syndrome).
Reviewed 8/19/21

MBP 100.0 Elelyso (taliglucerase alfa)
Elelyso (taliglucerase alfa) is a hydrolytic lysosomal glucocerebroside-specific enzyme indicated for long-term enzyme replacement therapy (ERT) for adults with a confirmed diagnosis of Type 1 Gaucher disease.
Reviewed 1/19/21

MBP 29.0 Elitek (rasburicase)
Elitek (rasburicase) is an intravenously administered recombinant urate-oxidase enzyme, which converts uric acid to allantoin (an inactive and soluble metabolite of uric acid); it does not inhibit the formation of uric acid.
Reviewed 8/19/21

MBP 197.0 Elzonris (Tagraxofusp-erzs)
Elzonris (Tagraxofusp-erzs) is a CD123-directed fusion protein which is composed of human interleukin-3 (IL-3) and truncated diphtheria toxin (DT). After binding to CD123, tagraxofusp is internalized, leading to inhibition of protein synthesis and cell death
Reviewed 1/28/21

MBP 104.0 Emend IV (fosaprepitant)
Emend IV (fosaprepitant) is a substance P/neurokinin (NK1) receptor antagonist indicated for the prevention of acute and delayed nausea and vomiting associated with moderately-and highy-emetogenic chemotherapy (in combination with other antiemetics)
Reviewed 10/20/20

MBP 140.0 Empliciti (elotuzumab)
Empliciti (elotuzumab) is a humanized immunoglobulin G1 (IgG1) immunostimulatory monoclonal antibody directed against signaling lymphocytic activation molecule family member 7 (SLAMF7, also called CS1 [cell surface glycoprotein CD2 subset 1]). Empliciti is indicated in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma who have received one to three prior therapies.
Reviewed 8/20/21

MBP 208.0 Enhertu (fam-trastuzumab deruxtecan-nxki)
Enhertu (fam-trastuzumab deruxtecan-nxki) is a HER2-directed antibody and topoisomerase inhibitor conjugate that binds to HER2 on tumor cells, undergoes internalization and intracellular linker cleavage by lysosomal enzymes, and upon release, causes DNA damage and apoptotic cell death.
Revised 3/16/21

MBP 118.0 Entyvio (vedolizumab)
Entyvio (vedolizumab) is a humanized monoclonal antibody indicated for the treatment of Crohn’s Disease and Ulcerative Colitis.
Reviewed 7/20/21

MBP 53.0 Eraxis (anidulafungin)
Eraxis (anidulafungin) is an echinocandin antifungal agent that results in the inhibition of β-1,3-D-glucan synthase, an essential component of fungal cell walls.
Revised 3/16/21

MBP 95.0 Erwinaze (aspiraginase)
Erwinaze (aspiraginase) is an amino acid that is essential for cell growth; it is produced by most, but not all cells. Mutated cancer cells in acute lymphoblastic leukemia (ALL) rely on asparagine circulating in the blood for growth. L-asparaginases are a group of enzymes that lower circulating asparagine levels in the blood, thereby depriving the mutated blood cells of asparagine and inhibiting their growth.
Reviewed 1/1/21

MBP 49.0 Erythropoietin and Darbepoetin Therapy
Erythropoietin therapy (e.g., EPO, Epogen® [epoetin alfa], epoetin beta, Procrit®,) and darbepoetin alfa therapy (Aranesp®) is used to stimulate red blood cell production in the bone marrow, with the goal of correcting anemia, minimizing the need for transfusion requirements, and improving the anemic insured individual’s quality of life.
Reviewed 10/5/21

MBP 202.0 Evenity (romosozumab-aqqg)
Evenity (romosozumab-aqqg) is a sclerostin inhibitor monoclonal antibody that inhibits sclerostin, a regulatory factor in bone metabolism that inhibits Wnt/Beta-catenin signaling pathway regulating bone growth; romosozumab increases bone formation and to a lesser extent, decreases bone resorption.
Reviewed 8/23/21

MBP 148.0 Exondys 51 (eteplirsen)
Exondys 51 (eteplirsen) binds to exon 51 of dystrophin pre-messenger RNA (mRNA), resulting in exclusion of this exon during mRNA processing. Exon skipping allows for production of an internally truncated dystrophin protein. Eteplirsen is indicated in the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping.
Reviewed 7/9/21

MBP 94.0 Eylea (aflibercept)
Eylea (aflibercept) is a recombinant fusion protein that acts as a decoy receptor for vascular endothelial growth factor-A (VEGF-A) and placental growth factor (PLGF). Aflibercept binds to VEGF-A and PLGF and inhibits binding and activating of endothelial cell receptors, thereby suppressing neovascularization and slowing vision loss.
Reviewed 9/8/21

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