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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 18.0 Fabrazyme (agalsidase beta)
Fabrazyme (agalsidase beta) is approved by the FDA for use in members with Fabry disease. Fabry disease is a progressive X-linked genetic disorder which causes a deficiency in the enzyme alpha-galactosidase A. This deficiency allows glycosphingolipids to accumulate in the vascular endothelium and visceral tissues throughout the body.
Revised 7/24/23

MBP 173.0 Fasenra Prefilled Syringe (benralizumab)
Fasenra (benralizumab), a humanized monoclonal antibody (IgG1, kappa), is an interleukin-5 antagonist. 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). Benralizumab, by inhibiting IL-5 signaling, reduces the production and survival of eosinophils.
Revised 5/11/23

MBP 240.0 Fensolvi (leuprolide injection)
Leuprolide is an agonist of gonadotropin releasing hormone (GnRH) receptors. Acting as a potent inhibitor of gonadotropin secretion, leuprolide produces an initial increase in luteinizing hormone (LH) and follicle stimulating hormone (FSH), which leads to a transient increase in testosterone and dihydrotestosterone (in males) and estrone and estradione (in premenopausal females). Continuous leuprolide administration then results in suppression of ovarian and testicular steroidogenesis due to decreased levels of LH and FSH with subsequent decrease in testosterone (male) and estrogen (female) levels. In males, testosterone levels are reduced to below castrate levels. Leuprolide may also have a direct inhibitory effect on the testes, and act by a different mechanism not directly related to reduction in serum testosterone.
Revised 7/12/23

MBP 219.0 Fetroja (cefiderocol)
Fetroja (cefiderocol) is a siderophore cephalosporin. A catechol side chain promotes formation of chelated complexes with ferric iron, allowing use of iron transport systems to deliver cefiderocol across the outer membrane of gram-negative bacilli. The cephalosporin moiety binds to penicillin-binding proteins which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis.
Revised 2/20/23

MBP 61.0 Flolan or Veletri (epoprostenol)
Flolan or Veletri (epoprostenol) is a man-made form of a naturally occurring molecule in the human body called prostaglandin which helps the body open blood vessels.
Revised 12/6/23

MBP 262.0 Fyarro (sirolimus protein-bound particles for injectable suspension) (albumin-bound)
Sirolimus (protein bound) is an albumin-bound nanoparticle sirolimus formulation that inhibits mammalian (mechanistic) target of rapamycin (mTOR). mTOR controls key cellular processes such as cell survival, growth, and proliferation, and is commonly dysregulated in several human cancers. In cells, sirolimus forms an immunosuppressive complex, sirolimus-FKBP-12 complex, which binds to and inhibits activation of the mTOR complex 1 (mTORC1). Inhibition of mTOR by sirolimus reduces cell proliferation, angiogenesis, and glucose uptake. In preclinical models, intravenous administration of nanoparticle protein bound sirolimus has demonstrated higher intratumor accumulation, greater mTOR inhibition, and higher tumor growth inhibition compared to oral mTOR inhibitors.
Revised 6/6/23

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