BlueCross BlueShield of Tennessee Medical Policy Manual

Specialty Medications by Trade Name

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Abatacept

Actemra®

Acthar® Gel - H.P.

Active Specific Immunotherapy: Melanoma Vaccine

Adcetris™

Aflibercept

Agalsidase Beta

Aldurazyme®

Alefacept

Alemtuzumab

Alglucosidase Alfa

Alimta®

Alpha 1-Proteinase Inhibitor (Human)

Amevive®

AmpliChip CYP450 Test

Aralast® / Aralast NP

Aranesp®

Arzerra™

Avastin®

Azacitidine

Banzel™

Belimumab

Bendamustine

Benlysta®

Berinert®

Bevacizumab for the Treatment of Neoplastic Disease

Bionect®

Bortezomib

Botox®

Botulinum Toxin

Brentuximab Vedotin

C1 Esterase Inhibitor

Cabazitaxel

Campath®

Canakinumab

Carimune® NF

Cerezyme®

Certolizumab Pegol

Cervarix®

Cetuximab

Cimzia®

Cinryze®

Collagenase Clostridium Histolyticum for Dupuytren’s Contracture

Corticotropin Therapy

Crisantaspase

Cytochrome p450 Genotyping

Darbepoetin Alfa

Degarelix Acetate

Denosumab

Dysport®

Eculizumab

Eligard®

Epoetin Alfa

Epogen®

Epoprostenol Sodium

Erbitux®

Eribulin Mesylate

Erwinaze™

Erythropoiesis-Stimulating Agents (ESAs)

Euflexxa®

Eylea™

Fabrazyme®

Factor VIIa (Recombinant)

Filgrastim

Firmagon®

Flebogamma®

Flolan®

Folotyn®

Galsulfase (Systemic)

Gammagard® S/D / Gammagard® Liquid

Gamunex®

Gardasil®

H.P. Acthar® Gel

Halaven®

Healon® / Healon5® / Healon GV®

Human Papillomavirus (HPV) Vaccine

Hyalgan®

Hyaluronan Derivatives

Ilaris®

Imiglucerase

Infliximab

Ipilimumab

Istodax®

Jevtana®

Krystexxa™

Laronidase

Leuprolide Acetate

Lumizyme™

Lupron®, Lupron Depot®, Lupron Depot-Ped®, Lupron Depot®-3 month, Lupron Depot®-4 month

Myobloc®

Myozyme®

Naglazyme®

Natalizumab

Neulasta®

Neupogen®

NovoSeven® / NovoSeven® RT

Ofatumumab

Omalizumab

Orencia®

Orthovisc®

Palivizumab

Panitumumab

Pegfilgrastim

Pegloticase

Pemetrexed

Photofrin®

Pralatrexate

Privigen®

Procrit®

Prolastin®

Prolia®

Provenge®

ProVisc®

Reclast®

Remicade®

Remodulin®

Rh0(D) Immune Globulin

Rhophylac®

Rituxan®

Rituximab (Systemic)

Romidepsin

RotaTeq® / Rotarix®

Rotavirus Vaccine

Rufinamide

Sipuleucel-T

Soliris®

Stelara™

Supartz®

Suprachoroidal Delivery of Pharmacologic Agents

Synagis®

Synvisc® / Synvisc-One®

Temodar®

Temozolomide

Tocilizumab

Treanda®

Treprostinil

Tysabri®

Tyvaso®

Ustekinumab

Vectibix®

Velaglucerase Alfa

Velcade®

Veletri®

Vidaza®

Vpriv™

WinRho®

Xgeva®

Xiaflex™

Xolair®

Yervoy™

Zemaira®

Zoledronic Acid

Zometa®

Zostavax®

Zoster Vaccine, Live