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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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M

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
Reviewed 3/29/18

MBP 111.0 Marqibo (vincristine sulfate liposome injection)
Marqibo (vincristine sulfate liposome injection) is a sphiingomyelin/cholesterol liposome-encapsulated formulation of vincristine sulfate
Reviewed 3/29/18

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.
New Policy 5/15/18

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.
Reviewed 3/29/18

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.
New Policy 1/16/18

MBP 55.0 Myozyme (alglucosidase alfa)
Myozyme (alglucosidase alfa) is a recombinant formulation of the human enzyme acid a-glucosidase (GAA), designed for intravenous infusion. The drug is designed to replace GAA deficiencies in individuals with Pompe disease.
Reviewed 10/31/17

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