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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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P

MBP 168.0 Parsabiv (etelcalcetide)
Parsabiv (etelcalcetide), a calcium-sensing receptor agonist, is a synthetic peptide calcimimetic agent that allosterically binds and activates the calcium-sensing receptor (CaSR) on parathyroid chief cells.  This action on the parathyroid gland sensitizes CaSR to promote negative feedback, thus decreasing PTH secretion and serum calcium and phosphorus levels.
Reviewed 11/1/19

MBP 200.0 Polivy (polatuzumab vedotin-piiq)
Polivy (polatuzumab vedotin-piiq) is an antibody drug conjugate (ADC) directed at CD79b which consists of 3 components: 1) a CD79b-specific humanized IgG1 antibody; 2) a microtubule-disrupting agent, monomethylauristatin E (MMAE); and 3) a protease cleavable linker (which covalently conjugates MMAE to the polatuzumab antibody). The conjugate binds to CD79b (B-cell specific cell surface protein commonly expressed in mature B cell lymphomas, and forms a complex which is internalized within the cell and releases MMAE. MMAE binds to the tubules and disrupts the cellular microtubule network, inducing cell cycle arrest (G2/M phase) and apoptosis.
New Policy 7/16/19

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.
Reviewed 8/29/19

MBP 185.0 Poteligeo (mogamulizumab-kpkc)
Poteligeo (mogamulizumab-kpkc) is a first-in-class defucosylated, humanized IgG1 kappa monoclonal antibody which selectively binds to C-C chemokine receptor 4 (CCR4). CCR4 mediates cell trafficking of lymphocytes to skin and various organs and is consistently expressed on the surface of T-cell malignancies (eg, mycosis fungoides, Sézary syndrome, adult T-cell leukemia/lymphoma, peripheral T-cell lymphoma) (Kim 2018). Mogamulizumab-kpkc binding to CCR4 targets a cell for antibody-dependent cellular cytotoxicity (ADCC), resulting in target cell depletion.
Reviewed 2/1/20

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
Reviewed 8/29/19

MBP 177.0 Prevymis IV (letermovir)
Prevymis IV (letermovir) is an antiviral agent that inhibits cytomegalovirus (CMV) replication by targeting the CMV DNA terminase complex (pUL51, pUL56, pUL89), which is required for viral DNA processing and packaging. Letermovir affects production of genome unit lengths and alters virion maturation.
Reviewed 1/1/20

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.
Reviewed 8/29/19

 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.
Reviewed 9/15/19

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
Reviewed 1/1/20

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