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

L

MBP 147.0 Lartruvo (olaratumab)
Lartruvo (olaratumab) is a human (recombinant) IgG1 antibody which expressly binds to platelet-derived growth receptor alpha (PDGFR-alpha) to prevent binding of PDGF-AA, PDGF-BB, and PDGF-CC, and block receptor activation and disrupt PDGF receptor signaling. The PDGF-alpha receptor has a role in cell differentiation, growth, and angiogenesis, and has demonstrated antitumor activity in sarcomas.
New Policy 1/17/17

MBP 125.0 Lemtrada (alemtuzumab)
Lemtrada (alemtuzumab) is a CD52-directed cytolytic monoclonal antibody indicated for the treatment of patients with relapsing forms of multiple sclerosis (MS). Because of its safety profile, the use of Lemtrada should be generally reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.
Revised 9/20/16

MBP 83.0 Lumizyme (alglucosidase alfa)
Lumizyme (alglucosidase alfa) is a lysosomal glycogen-specific enzyme indicated for patients with Pompe disease [acid alpha-glucosidase (GAA) deficiency]. Lumizyme (alglucosidase alfa) provides an exogenous source of GAA allowing conversion of glycogen to energy in heart and muscle cells.
Reviewed 3/30/17

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