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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:



MBP 127.0 Makena (hydroxyprogesterone caproate)
Makena (hydroxyprogesterone caproate) is a synthetic progestin indicated for reducing the risk of preterm birth in women with a singleton pregnancy who have a history of singleton spontaneous preterm birth. It is not intended for use in women with multiple gestations or other risk factors for preterm birth and is contraindicated in women with current or history of thrombosis or thromboembolic disorder, known or suspected breast cancer, other hormone-sensitive cancer, or history of these conditions, undiagnosed abnormal vaginal bleeding unrelated to pregnancy, cholestatic jaundice of pregnancy, liver tumors, benign or malignant, or active liver disease or uncontrolled hypertension
Revised 1/16/23

MBP 231.0 Margenza (margetuximab-cmkb)
Margenza (margetuximab-cmkb) is a chimeric Fc-engineered IgG1 kappa monoclonal antibody and human epidermal growth factor receptor (HER2) antagonist. Margetuximab binds to HER2-expressing tumor cells and inhibits tumor cell proliferation, reduces shedding of the HER2 extracellular domain, and mediates antibody-dependent cellular cytotoxicity (ADCC). The modified Fc region of margetuximab increases in vitro binding to the activating Fc receptor and decreases binding to the inhibitory Fc receptor, leading to greater in vitro ADCC and NK cell activation.
Revised 3/31/23

MBP 33.0 Medical Benefit Pharmaceutical Administrative Policy
This policy explains how coverage decisions are determined for GHP members who have medical drug benefits, including Commercial, Affordable Care Act (ACA), GHP Kids, Self-Insured plans, Medicare and Medicaid, unless a specific limitation, exception, or exclusion exists. Coverage exceptions include decisions about the medical necessity of a specific drug, decisions about drugs exceeding quantity limits, and decisions whether a member has satisfied prior authorization requirements, or site of care requirements. The policy is utilized when a drug specific policy does not exist or the existing drug specific policy does not address the requested indication or process.
Revised 12/15/22

MBP 175.0 Mepsevii (vestronidase alfa-vjbk)
Mepsevii (vestronidase alfa-vjbk) is a recombinant human beta-glucuronidase (GUS), which provides exogenous GUS enzyme for uptake into cellular lysosomes. Mannose-6-phosphate (M6P) residues on the oligosaccharide chains allow binding of the enzyme to cell surface receptors, leading to cellular uptake of the enzyme, targeting to lysosomes and subsequent catabolism of accumulated glycosaminoglycans (GAGs) in affected tissues.
Revised 12/17/22

MBP 130.0 Mircera (methoxy polyethylene glycol-epoetin beta)
Mircera (methoxy polyethylene glycol-epoetin beta) is an erythropoiesis-stimulating agent (ESA) indicated for the treatment of anemia associated with chronic kidney disease (CKD) in adult patients on dialysis and patients not on dialysis.
Revised 11/15/22

MBP 221.0 Monjuvi (tafasitamab-cxix)
Monjuvi (tafasitamab-cxix) is a humanized CD19-directed, Fc-modified monoclonal antibody that binds to CD19 antigen, which is expressed on the surface of pre-B and mature B lymphocytes and on several B-cell malignancies, including diffuse large B-cell lymphoma. After binding to CD19, tafasitamab mediates B-cell lysis through apoptosis and immune effector mechanisms, including antibody-dependent cellular cytotoxicity and phagocytosis. Administering in combination with lenalidomide results in increased antibody-dependent cellular cytotoxicity activity compared to either agent alone.
Revised 9/15/22

MBP 163.0 Mylotarg (gemtuzumab ozogamicin)
Mylotarg (gemtuzumab ozogamicin) is a humanized CD-33 directed monoclonal antibody-drug conjugate, which is composed of the IgG4 kappa antibody gemtuzumab linked to a cytotoxic calicheamicin derivative.
Revised 8/22/22

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