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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:

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N

MBP 39.0 Naglazyme (galsulfase)
Naglazyme (galsulfase) is a normal variant form of the polymorphic human enzyme N-acetylgalactosamine 4-sulfatase that is produced by recombinant DNA technology.
Reviewed 8/19/21

MBP 68.0 Nplate (romiplostim)
Nplate (romiplostim) is used for the treatment of chronic immune (idiopathic) thrombocytopenia purpura (ITP). Its mechanism of action increases platelet production through binding and activation of the thrombopoietin (TPO) receptor with a mechanism analogous to endogenous TPO. 
Reviewed 7/20/21

MBP 141.0 Nucala vial (mepolizumab)
Nucala (mepolizumab) is an interleukin-5 antagonist (immunoglobulin G1 [IgG1] kappa). IL-5 is the major cytokine responsible for the growth and differentiation, recruitment, activation, and survival of eosinophils (a cell type associated with inflammation and (an important component of the pathogenesis of asthma). Mepolizumab, by inhibiting interleukin-5 signaling, reduces the production and survival of eosinophils; however, the mechanism of mepolizumab action in asthma has not been definitively established.
Revised 3/16/21

MBP 238.0 Nulibry (fosdenopterin)
Nulibry (fosdenopterin) is a cyclic pyranopterin monophosphate that undergoes conversion to molybdopterin, which is further converted to molybdenum cofactor. Molybdenum cofactor is required for molybdenum-dependent enzyme activation, including sulfite oxidase, which reduces levels of neurotoxic sulfites (eg, S-sulfocysteine).
New Policy 7/20/21

MBP 93.0 Nulojix (belatacept)
Nulojix (belatacept) is a selective T-cell costimulation blocker indicated for prophylaxis of organ rejection in adult patients receiving a kidney transplant.
Reviewed 9/23/21

MBP 203.0 Nuzyra (omadacycline)
Nuzyra (omadacycline) is a tetracycline derivative antibiotic that inhibits protein synthesis by binding with the 30S ribosomal subunit of susceptible bacteria.
Reviewed 11/2/20

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