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Medical benefit pharmaceutical policies for providers

See the latest updates to our medical benefit pharmaceutical policies. 

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MBP 167.0 Vabomere (meropenem/vaborbactam)
Vabomere (meropenem/vaborbactam) is an antibacterial drug containing a combination of meropenem, a penem antibacterial, and vaborbactam, a beta-lactamase inhibitor. 
Revised 9/23/22

MBP 253.0 Vabysmo (faricimab)
Faricimab is a recombinant humanized bispecific antibody that inhibits vascular endothelial growth factor A (VEGF-A), resulting in suppression of endothelial cell proliferation, neovascularization, and vascular permeability. Faricimab also inhibits angiopoietin-2 (Ang-2), which promotes vascular stability and desensitizes blood vessels to effects of VEGF-A.
Revised 10/23/23

MBP 171.0 Varubi IV (rolapitant)
Varubi IV (rolapitant) is a substance P/neurokinin (NK1) receptor antagonist that prevents delayed nausea and vomiting associated with emetogenic chemotherapy by selectively and competitively inhibiting the substance P/neurokinin 1 (NK1) receptor.
Revised 1/8/24

MBP 50.0 Vectibix (panitumumab)
Vectibix (panitumumab) is a recombinant, human IgG2 kappa monoclonal antibody that binds specifically to the human Epidermal Growth Factor Receptor (EGFR). Overexpression of EGFR is detected in many human cancers, including those of the colon and rectum. When Vectibix binds to EGFR it inhibits the binding of ligands for EGFR. This results in inhibition of cell growth, induction of apoptosis, decreased pro-inflammatory cytokine and vascular growth factor production.
Revised 8/9/23

MBP 23.0 Velcade (bortezomib)
Velcade (bortezomib) is an antineoplastic agent available for intravenous injection, designed specifically to inhibit proteasomes. The proteasome is an enzyme complex that exists in all cells and plays an important role in degrading proteins that control the cell cycle and cellular processes. By blocking the proteasome, Velcade® disrupts numerous biologic pathways, including those related to the growth and survival of cancer cells
Revised 7/24/23

MBP 61.0 Veletri or Flolan (epoprostenol)
Flolan or Veletri (epoprostenol) is a man-made form of a naturally occurring molecule in the human body called prostaglandin which helps the body open blood vessels.
Revised 12/6/23

MBP 312.0 Veopoz (pozelimab-bbfg)
Pozelimab-bbfg is a human, monoclonal immunoglobulin G4P (IgG4P ) antibody directed against the terminal complement protein C5 that inhibits terminal complement activation by blocking cleavage of C5 into C5a (anaphylatoxin) and C5b, thereby blocking the formation of the membrane-attack complex (C5b-C9, a structure mediating cell lysis).
New Policy 1/16/24

MBP 226.0 Viltepso (viltolarsen)
Viltepso (viltolarsen) is an antisense oligonucleotide that binds to exon 53 of dystrophin premessenger RNA (mRNA), resulting in exclusion of this exon during mRNA processing. Exon 53 skipping allows for production of an internally truncated dystrophin protein in patients with genetic mutations that are amenable to exon 53 skipping.
Revised 1/2/24

MBP 114.0 Vimizim (elosulfase alfa)
Vimizim (elosulfase alfa) acts to provide the exogenous enzyme GALNS that is taken up into the lysosomes and increases the catabolism of the GAGs KS and C6S.
Revised 8/18/23

MBP 13.0 Viscosupplementation using hyaluronan injections (Gel-One, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Visco-3)
Hyaluronan, also known as hyaluronic acid, is a naturally occurring macromolecule that is a major component of synovial fluid. In osteoarthritis, there are changes in the quality and quantity of hyaluronan in the synovial fluid and cartilage. Intra-articular injection of hyaluronan has been proposed as a means of restoring viscoelasticity of the synovial fluid in patients with osteoarthritis. This treatment is also known as viscosupplementation.
Revised 8/25/23

MBP 96.0 Voraxaze (glucarpidase)
Voraxaze (glucarpidase) is a recombinant bacterial enzyme that hydrolyzes the carboxyl-terminal glutamate residue from folic acid and classical antifolates such as methotrexate. Voraxaze converts methotrexate to its inactive metabolites 4-deoxy-4-amino-N10-methylpteroic acid (DAMPA) and glutamate. Voraxaze provides an alternative non-renal pathway for methotrexate elimination in patients with renal dysfunction during high-dose methotrexate treatment
Reviewed 9/22/21

MBP 105.0 VPRIV (velaglucerase alfa)
VPRIV (velaglucerase alfa) is a hydrolytic lysosomal glucocerebroside–specific enzyme indicated for long-term enzyme replacement therapy for pediatric and adult insured individuals with type 1 Gaucher disease.
Revised 12/31/23

MBP 218.0 Vyepti (eptinezumab-jjmr)
Vyepti (eptinezumab-jjmr) is a humanized monoclonal antibody that binds to calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor.
Revised 6/2/23

MBP 306.0 Vyjuvek (beremagene geperpavec-svdt)
Beremagene geperpavec is a herpes simplex virus-1 (HSV-1) vector-based gene therapy that may transduce both keratinocytes and fibroblasts within the nucleus of the cells allowing for production and secretion of COL7; the COL7 molecules form anchoring fibrils, which hold the epidermis and dermis together and help maintain skin integrity. Patients with dystrophic epidermolysis bullosa have lower than normal or no functioning anchoring fibrils.
New Policy 11/21/23

MBP 214.0 Vyondys 53 (golodirsen)
Vyondys 53 (golodirsen) is an antisense oligonucleotide which binds exon 53 of dystrophin pre-mRNA, which results in exclusion of exon 53 during mRNA processing in patients with genetic mutations that are amenable to exon 53 skipping.  Exon 53 skipping causes production of a truncated dystrophin protein in these patients. Vyondys 53 is indicated in the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 53 skipping.

This indication is approved under accelerated approval based on an increase in dystrophin production in skeletal muscle observed in patients treated with Vyondys 53. Continued approval for this indication may be contingent upon verification of a clinical benefit in confirmatory trials.
Revised 1/2/24

MBP 260.0 Vyvgart (efgartigimod alfa-fcab)
Vyvgart (efgartigimod alfa-fcab) is a human IgG1 antibody fragment that binds to the neonatal Fc receptor (FcRn), resulting in the reduction of circulating IgG antibodies, including acetylcholine receptor (AChR) autoantibodies, that cause neuromuscular junction (NMJ) damage and dysfunction.
Revised 1/1/24

MBP 164.0 Vyxeos (daunorubicin/cytarabine liposomal)
Vyxeos (daunorubicin/cytarabine liposomal) is a combination product with a fixed 1:5 (daunorubicin:cytarabine) molar ratio; this ratio has been shown to have synergistic effects in killing leukemia cells in vitro and in animal models. Daunorubicin (conventional) inhibits DNA and RNA synthesis by intercalation between DNA base pairs and by steric obstruction. Daunomycin intercalates at points of local uncoiling of the double helix. Although the exact mechanism is unclear, it appears that direct binding to DNA (intercalation) and inhibition of DNA repair (topoisomerase II inhibition) result in blockade of DNA and RNA synthesis and fragmentation of DNA. Cytarabine (conventional) is a pyrimidine analog and is incorporated into DNA; however, the primary action is inhibition of DNA polymerase resulting in decreased DNA synthesis and repair. The degree of cytotoxicity correlates linearly with incorporation into DNA; therefore, incorporation into the DNA is responsible for drug activity and toxicity. Cytarabine is specific for the S phase of the cell cycle (blocks progression from the G1 to the S phase). 
Revised 3/31/23

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