Medical Benefit Pharmaceutical Policies for Providers
See the latest updates to our medical benefit pharmaceutical policies.
MBP 142.0 Portrazza (necitumumab)
Portrazza is a recombinant human IgG1 EGFR monoclonal antibody that binds (with a high affinity) to the ligand binding site of the EGFR receptor to prevent receptor activation and downstream signaling.
MBP 143.0 Praxbind (idarucizumab)
Praxbind (idarucizumab), a specific reversal agent for Pradaxa (dabigatran), is a humanized monoclonal antibody fragment (Fab) that binds specifically to dabigatran and its acylglucuronide metabolites with an affinity for dabigatran that is approximately 350 times greater than that of thrombin, and neutralizes the anticoagulant effect within minutes
MBP 58.0 Prialt (ziconotide intrathecal infusion)
Prialt (ziconotide intrathecal infusion) is a non-opioid analgesics categorized as an N-type calcium channel blocker (NCCB). Prialt is the synthetic equivalent of a naturally occurring conopeptide found in a marine snail known as Conus magus. Research in animals suggests that Prialt works by targeting and blocking N-type calcium channels on nerves in the spinal cord that ordinarily transmit pain signals.
MBP 146.0 Probuphine (buprenorphine)
Probuphine (buprenorphine) is a partial opioid agonist indicated for the maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses of a transmucosal buprenorphine containing product.
New Policy 3/15/17
MBP 81.0 Prolia (denosumab)
Prolia (denosumab) is a human IgG2 monoclonal antibody (fully human, lab-produced antibody) that inactivates the body's bone-breakdown mechanism by targeting a chemical signal called RANK ligand, an essential part of the body's natural process for breaking down bone.
MBP 79.0 Provenge (sipuleucel-T)
Provenge (sipuleucel-T) is an immunotherapy product consisting of autologous dendritic cells loaded ex vivo with a recombinant fusion protein. The goal of therapy is to induce therapeutic immunity against prostate cancer cells by targeting the PAP tumor antigen, which is expressed on greater than 95% of prostate cancer cells
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