Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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R

MBP 154.0 Radicava (edaravone)
Radicava (edaravone) is a free radical scavenger with anti-oxidative properties that protects motor neurons from oxidative stress and damage.  Oxidative signaling pathways and stress are hypothesized as contributory in the early pathogenesis of amyotrophic lateral sclerosis (ALS).
New Policy 7/18/17

MBP 5.0 Remicade (infliximab) or Inflectra (infliximab-dyyb)
Infliximab is a therapeutic agent that inhibits activity of tumor necrosis factor alpha (TNF-alpha), a biological response mediator of inflammation. TNF-alpha is a key inflammatory mediator in rheumatoid arthritis, Crohn’s disease and other autoimmune disorders. In these chronic conditions, overproduction of TNF-alpha leads to inflammation. Infliximab reduces inflammation by binding to and neutralizing TNF- alpha on the cell membrane and in the blood.
Revised 3/21/17

MBP 62.0 Remodulin IV (treprostinil sodium) 
Remodulin IV (treprostinil sodium) is a type of medication called a prostaglandin analog which helps the body open blood vessels located within pulmonary and systemic vascular beds.
Revised 9/5/17

MBP 48.0 Rituxan (rituximab)
Rituxan (rituximab) is a genetically engineered chimeric murine/human monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant B lymphocytes. Rituximab has been shown to be effective in rheumatoid arthritis in three randomized controlled trials and is now FDA-approved for use in combination with methotrexate (MTX) for reducing signs and symptoms in adult patients with moderately- to severely-active rheumatoid arthritis (RA) who have had an inadequate response to one or more tumor necrosis factor (TNF) antagonist therapies.
Reviewed 7/31/17

MBP 124.0 Ruconest (C1 esterase inhibitor, recombinant)
Ruconest (C1 esterase inhibitor, recombinant) is indicated for the treatment of acute hereditary angioedema (HAE) attacks in adults and adolescent patients.  Ruconest is a recombinant C1 esterase inhibitor (rhC1INH) which irreversibly binds target proteases (activated C1s, kallikrein, factor XIIa, and factor XIa) of the contact and complement systems.
Reviewed 3/30/17

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