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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:



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).
Reviewed 1/28/21

MBP 210.0 Reblozyl (luspatercept-aamt)
Reblozyl (luspatercept-aamt) is a recombinant fusion protein that contains a modified form of the extracellular domain of human activin receptor type IIb and links to the human IgG1 Fc domain. It binds several endogenous transforming growth factor-beta (TGF-β) superfamily ligands, which results in reduced Smad2/3 signaling. Inhibition of TGF-β superfamily results in increased differentiation and proliferation of erythroid precursors and improves hematology parameters associated with ineffective erythropoiesis
Updated 9/15/20

MBP 215.0 Recarbrio (imipenem/cilastatin/relebactam)
Recarbrio (imipenem/cilastatin/relebactam) is a carbapenem antimicrobial that contains imipenem, which inhibits penicillin-binding proteins and leads to the disruption of bacterial cell wall synthesis.  Recarbio also contains cilastatin, which is a renal dehydropeptidase inhibitor that limits the renal metabolism of imipenem, and relebactam, which is a beta-lactamase inhibitor that protects imipenem from degradation by beta-lactamases.
Revised 11/17/20

MBP 5.0 Remicade (infliximab) or Inflectra (infliximab-dyyb) or Renflexis (infliximab-abda)
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.
Reviewed 1/19/21

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 3/12/21

MBP 193.0 Revcovi (elapegademase-lvlr)
Revcovi (elapegademase-lvlr) is an exogenous source of adenosine deaminase enzyme. Adenosine deaminase is an enzyme that catalyzes the deamination of both adenosine and deoxyadenosine. Hereditary lack of adenosine deaminase activity results in severe immunodeficiency disease, an often fatal disorder. Elapegademase-lvlr in effect, reduces levels of toxic adenosine and deoxyadenosine and increases lymphocytes.
Reviewed 1/1/21

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 1/1/21

MBP 165.0 Rituxan Hycela (rituximab/hyaluronidase)
Rituxan Hycela is a combination product containing rituximab and hyaluronidase. Rituximab is a monoclonal antibody directed against the CD20 antigen on the surface of pre-B and mature B-lymphocytes. CD20 regulates cell cycle initiation; and, possibly, functions as a calcium channel. Rituximab binds to the antigen on the cell surface, activating complement-dependent B-cell cytotoxicity; and to human Fc receptors, mediating cell killing through an antibody-dependent cellular toxicity. Hyaluronidase increases the absorption rate of rituximab-containing products by increasing permeability of subcutaneous tissue through temporary depolymerization of hyaluronan
Reviewed 1/1/21

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 1/19/21

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