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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

F

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.
Reviewed 8/3/21

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.
Reviewed 10/4/21

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.
New policy 7/20/21

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 3/16/21

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.
Reviewed 12/21/21

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