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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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K

MBP 108.0 Kadcyla (ado-trastuzumab emtansine)
Kadcyla (ado-trastuzumab emtansine) is a HER2-targeted antibody and microtubule inhibitor conjugate.
Reviewed 3/29/18

MBP 86.0 Kalbitor (ecallantide)
Kalbitor (ecallantide) is a human plasma kallikrein inhibitor produced in Pichia pastoris yeast cells by recombinant DNA technology.
Reviewed 3/29/18

MBP 180.0 Kanuma (sebelipase alfa)
Kanuma (sebelipase alfa) is a form of enzyme replacement therapy that binds to cell surface receptors via glycans expressed on the protein and is subsequently internalized into lysosomes. Sebelipase alfa catalyzes the lysosomal hydrolysis of cholesteryl esters and triglycerides to free cholesterol, glycerol, and free fatty acids. In patients with lysosomal acid lipase (LAL) deficiency, replacement with sebelipase alfa, a recombinant form of LAL, results in improvement in disease-related hepatic and lipid parameters.
New Policy 7/17/18

MBP 119.0 Keytruda (pembrolizumab)
Keytruda (pembrolizumab) binds to the programmed death receptor-1 (PD-1) ligands, PD-L1 and PD-L2, to the PD-1 receptor found on T cells, inhibits T cell proliferation and cytokine production.
Revised 7/17/18

MBP 159.0 Kymriah (tisagenlecleucel)
Kymriah (tisagenlecleucel) is a CD19-directed genetically modified autologous T cell immunotherapy in which a patient's T cells are reprogrammed with a transgene encoding a chimeric antigen receptor (CAR) to identify and eliminate CD19-expressing malignant and normal cells.
New Policy 11/21/17

MBP 97.0 Kyprolis (carfilzomib)
Kyprolis (carfilzomib) is a tetrapeptide epoxyketone protease inhibitor that irreversibly binds to the N-terminal threonine – containing active sites of the 20S proteasome, the proteolytic core particle within the 26S proteasome.
Reviewed 1/24/18

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