Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 155.0 Ocrevus (ocrelizumab)
Ocrevus (ocrelizumab) is an anti-CD20 monoclonal antibody. The precise mechanism of ocrelizumab is unknown, but presumed to involve binding to CD20, a cell surface antigen present on pre-B and mature B lymphocytes. Following cell surface binding to B lymphocytes, ocrelizumab results in antibody-dependent cellular cytolysis and complement-mediated lysis.
MBP 92.0 Off-label Drug Use for Oncologic Indications
Off-label use of a drug or biologic may be determined to be medically necessary and medically accepted for an oncologic indication not included in the FDA approved labeling if it is supported in one or more drug compendia; is not specifically contraindicated, unsupported, or not recommended; and is supported by published clinical research data.
MBP 229.0 Olinvyk (oliceridine)
Olinvyk (oliceridine) is an opioid agonist that selectively binds to the G-protein section of the opioid mu receptor to induce analgesia. Reduced activation of the beta-arrestin pathway associated with opioid-related adverse events (eg, respiratory depression, GI effects)
New Policy 4/29/21
MBP 138.0 Onivyde (irinotecan liposome injection)
Onivyde (irinotecan liposome injection) is a topoisomerase inhibitor indicated, in combination with fluorouracil and leucovorin, for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy.
MBP 188.0 Onpattro (patisiran)
Onpattro (patisiran) is a double-stranded small interfering ribonucleic acid (siRNA) that causes degradation of mutant and wild-type transthyretin (TTR) mRNA through RNA interference, which results in a reduction of serum TTR protein and TTR protein deposits in tissues. Serum TTR is a carrier of retinol binding protein, which is involved in the transport of vitamin A in the blood.
MBP 126.0 Opdivo (nivolumab)
Opdivo (nivolumab) is a fully human immunoglobulin G4 (IgG4) monoclonal antibody that selectively inhibits programmed cell death 1 (PD-1) activity by binding to the PD-1 receptor to block the ligands PD-L1 and PD-L2 from binding. The negative PD-1 receptor signaling that regulates T-cell activation and proliferation is therefore disrupted. This releases PD-1 pathway-mediated inhibition of the immune response, including the antitumor immune response.
MBP 40.0 Orencia IV (abatacept)
Orencia (abatacept) is a selective T-cell co-stimulation modulator that inhibits T-cell activation by binding to CD80 and CD86 which blocks interaction with CD28. The interaction provides a co-stimulatory signal necessary for full activation of T-lymphocytes. Activated T-lymphocytes are found in the synovium of patients with rheumatoid arthritis (RA) and are implicated in the pathophysiology of RA.
MBP 234.0 Oxlumo (lumasiran)
Oxlumo (lumasiran) is a hydroxyacid oxidase 1 (HAO1)-directed small interfering ribonucleic acid (siRNA) that reduces the amount of available glyoxylate, a substrate for oxalate production, by targeting hydroxyacid oxidase 1 (HAO1) messenger RNA in hepatocytes through RNA interference, subsequently decreasing glycolate oxidase enzyme levels.
New policy 5/18/21
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