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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.
Revised 7/16/19

MBP 86.0 Kalbitor (ecallantide)
Kalbitor (ecallantide) is a human plasma kallikrein inhibitor produced in Pichia pastoris yeast cells by recombinant DNA technology.
Reviewed 2/1/20

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.
Reviewed 2/1/20

MBP 206.0 Khapzory (Levoleucovorin)
Khapzory (Levoleucovorin) is a chemotherapy modulating agent, folate analog. Levoleucovorin counteracts the toxic (and therapeutic) effects of folic acid antagonists (eg, methotrexate) which act by inhibiting dihydrofolate reductase. Levoleucovorin is the levo isomeric and pharmacologic active form of leucovorin (levoleucovorin does not require reduction by dihydrofolate reductase). A reduced derivative of folic acid, leucovorin supplies the necessary cofactor blocked by methotrexate. Leucovorin enhances the activity (and toxicity) of fluorouracil by stabilizing the binding of 5-fluoro-2’-deoxyuridine-5’-monophosphate (FdUMP; a fluorouracil metabolite) to thymidylate synthetase resulting in inhibition of this enzyme.
New Policy 12/20/19

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 11/19/19

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.
Reviewed 11/1/19

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 8/29/19

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