Medical benefit pharmaceutical policies for providers
See the latest updates to our medical benefit pharmaceutical policies.
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.
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.
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.
MBP 114.0 Vimizim (elosulfase alfa)
Vimizim (elosulfase alfa) acts to provide the exogenous enzyme GALNS that is taken up into the lysosomes and increased the catabolism of the GAGs KS and C6S.
MBP 13.0 Viscosupplementation using hyaluronan injections (Hyalgan, Orthovisc, Supartz, Monovisc, Gel-One)
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 (FDA-approved products include Euflexxa, Synvisc, Synvisc One, Orthovisc, Supartz, Hyalgan, Monovisc, and Gel-One) has been proposed as a means of restoring viscoelasticity of the synovial fluid in patients with osteoarthritis. This treatment is also known as viscosupplementation.
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
MBP 105.0 VPRIV (velaglucerase alfa)
VPRIV (velaglucerase alfa) is a hydrolytic lysosomal glucocerebroside –enzyme indicated for long-term enzyme replacement therapy for pediatric and adult insured individuals with type 1 Gaucher disease.
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.
New Policy 1/16/18
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