Medical Policy Manual

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BlueCross BlueShield of Tennessee Medical Policy Manual

Specialty Medications

View by Trade Name.

Abatacept (Orencia®)

AbobotulinumtoxinA (Dysport®)

ADAMTS13, recombinant-krhn (Adzynma)

Ado-Trastuzumab Emtansine (Kadcyla®)

Aducanumab-avwa (Aduhelm™)

Afamitresgene Autoleucel (Tecelra®)

Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Aflibercept-abzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])

Agalsidase Beta (Fabrazyme®)

Aldesleukin (Proleukin®)

Alemtuzumab (Lemtrada®)

Alglucosidase Alfa (Lumizyme®)

Allogeneic Processed Thymus Tissue - agdc (Rethymic®)

Alpha1-Proteinase Inhibitor (Aralast®-NP, Glassia®, Prolastin®-C, Zemaira®)

Amivantamab-vmjw (Rybrevant™)

Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro™)

Anifrolumab-fnia (Saphnelo™)

Asparaginase Erwinia chrysanthemi (recombinant)-rywn (Rylaze™) (Intramuscular)

Atezolizumab (Tecentriq®)

Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)

Atidarsagene Autotemcel (Lenmeldy™)

Avacincaptad Pegol (Izervay™)

Avalglucosidase Alfa-ngpt (Nexviazyme™)

Avelumab (Bavencio®)

Axatilimab-csfr (Niktimvo™)

Axicabtagene Ciloleucel ( Yescarta™ )

Azacitidine (Vidaza®)

Belantamab Mafodotin-blmf (Blenrep®)

Belimumab (Benlysta®)

Belinostat (Beleodaq®)

Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine)

Benralizumab (Fasenra®)

Beremagene Geperpavec-svdt (Vyjuvek™)

Betibeglogene autotemcel (Zynteglo®)

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)

Bioidentical Compounded Hormone Therapy

Blinatumomab ( Blincyto® )

Bortezomib (Velcade®, Bortezomib)

Brentuximab Vedotin (Adcetris®)

Brexucabtagene Autoleucel (Tecartus™)

Brolucizumab-dbll (Beovu®)

Burosumab-twza ( Crysvita®)

C1 Esterase Inhibitor (Berinert®)

C1 Esterase Inhibitor (Cinryze®)

C1 Esterase Inhibitor (Ruconest®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)

Cabazitaxel (Jevtana®)

Calaspargase Pegol-mknl (Asparlas®)

Canakinumab (Ilaris®)

Carfilzomib (Kyprolis®)

Casimersen (Amondys 45™)

Cemiplimab-rwlc (Libtayo®)

Cerliponase Alfa (Brineura®)

Certolizumab Pegol (Cimzia®)

Cetuximab (Erbitux®)

Ciltacabtagen Autoleucel (Carvykti™)

Cipaglucosidase Alfa-atga (Pombiliti™)

Collagenase (Xiaflex®)

Corticotropin-ACTH:[HP Acthar Gel (repository corticotropin injection), Cortrophin® Gel

Cosibelimab-ipdl (Unloxcyt™)

Crizanlizumab-tmca (Adakveo)

Crovalimab-akkz (Piasky®)

Daratumumab (Darzalex®)

Daratumumab and hyaluronidase-fihj /Darzalex Faspro®)

Darbepoetin Alfa (Aranesp®)

Datopotamab Deruxtecan-dlnk (Datroway®)

Daunorubicin and Cytarabine Liposome for Injection (Vyxeos™)

DaxibotulinumtoxinA-lanm (Daxxify™)

Degarelix (Firmagon®)

Delandistrogene moxeparvovec-rokl (Elevidys®)

Denileukin diftitox-cxdl (Lymphir™)

Denosumab Products: (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-bmwo (Stoboclo®)

Denosumab Products:(Xgeva®); Denosumab-kyqq (Aukelso™); Denosumab-nxxp (Bilprevda®); Denosumab-bnht (Bomyntra®); Denosumab-desu (Jubereq); Denosumab-bmwo (Osenvelt®); Denosumab-mobz (Oziltus®); Denosumab-bbdz (Wyost®); Denosumab-dssb (Xbryk™), Denosumab-qbde (Xtrenbo™)

Depemokimab-ulaa (Exdensur)

Dexamethasone Implant (Ozurdex®)

Donanemab-azbt (Kisunla™)

Dostarlimab-gxly (Jemperli®)

Durvalumab (Imfinzi®)

Ecallantide (Kalbitor®)

Eculizumab (Soliris®)

Edaravone (Radicava®)

Efbemalenograstim alfa-vuxw (Ryzneuta)

Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo)

Eflapegrastim-xnst (Rolvedon™)

Eladocagene exuparvovec-tneq (Kebilidi®)

Elapegademase-lvlr (Revcovi™)

Elivaldogene Autotemcel (Skysona®)

Elosulfase Alfa (Vimizim®)

Elotuzumab (Empliciti™)

Elranatamab-bcmm (Elrexfio™)

Emapalumab-lzsg (Gamifant™)

Enfortumab Vedotin-ejfv (Padcev™)

Epcoritamab-bysp (Epkinly™)

Epoetin Alfa Products (Epogen®, Procrit®, Retacrit®)

Epoprostenol for Continuous Intravenous Infusion (Flolan®, Veletri®)

Eptinezumab-jjmr (Vyepti®)

Eribulin Mesylate (Halaven®)

Eteplirsen ( Exondys 51™ )

Etranacogene Dezaparvovec-drlb (Hemgenix®)

Evinacumab-dgnba (Evkeeza ™ )

Exagamglogene Autotemcel (Casgevy™)

Fam-trastumzumab Deruxtecan-nxki (Enhertu®)

Faricimab-svoa (Vabysmo™)

Fidanacogene Elaparvovec-dzkt (Beqvez™)

Fluocinolone Acetonide Implant (Iluvien®)

Fluocinolone Acetonide Implant (Retisert®)

Fluocinolone Acetonide Implant (Yutiq ®)

Fosdenopterin (Nulibry™)

Galsulfase (Naglazyme®)

Gemcitabine (Inlexzo™) intravesical system

Gemtuzumab Ozogamicin (Mylotarg™)

Givosiran (Givlaari™)

Glofitamab-gxbm (Columvi™)

Golimumab for Intravenous Infusion (Simponi Aria®)

Golodirsen (Vyondys™)

Goserelin Acetate (Zoladex®)

Guselkumab (Tremfya®)

Histrelin Acetate (Supprelin® LA)

Hyaluronic Acid Derivatives

Ibalizumab-uiyk (Trogarzo™)

Icatibant (Firazyr®)

Idecabtageme Vicleucel (Abecma®)

Idursulfase (Elaprase®)

Imetelstat (Rytelo™)

Imiglucerase (Cerezyme®)

Inclisiran (Leqvio®)

IncobotulinumtoxinA (Xeomin®)

Inebilizumab-cdon (Uplizna™)

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™), Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), Infliximab

Inotersen (Tegsedi™)

Inotuzumab Ozogamicin (Besponsa®)

Intravenous Immune Globulin (IVIG

Ipilimumab (Yervoy®)

Irinotecan Liposome Injection (Onivyde™)

Isatuzimab-irfc (Sarclisa®)

Ixabepilone (Ixempra®)

Lanadelumab-flyo (Takhzyro®)

Lanreotide (Somatuline® Depot; Lanreotide*)

Laronidase (Aldurazyme®)

Lecanemab-irmb (Leqembi™)

Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)

Leuprolide Acetate Depot Suspension - [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide Acetate Depot (3-month 22.5 mg); Lutrate Depot (3-month 22.5 mg)

Leuprolide Acetate (Eligard®)

Leuprolide Acetate (Fensolvi®)

Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit)

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)

Levoleucovorin (Fusilev™), Levoleucovorin (Khapzory®), Levoleucovorin

Lifileucel (Amtagvi)

Linvoseltamab-gcpt (Lynozyfic™)

Lisocabtagene Maraleucel (Breyanzi®)

Loncastuximab Tesirine-lpyl (Zynlonta™)

Lovotibeglogene Autotemcel (Lyfgenia®)

Lumasiran (Oxlumo®)

Lurbinectedin (Zepzelca™)

Luspatercept-aamt (Reblozyl®)

Margetuximab-cmkb (Margenza™)

Mepolizumab (Nucala®)

Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)

Mirikizumab-mrkz (Omvoh)

Mirvetuximab Soravtansine-gynx (Elahere™)

Mitomycin Gel (Jelmyto™)

Mitomycin (Zusduri™)

Mogamulizumab-kpkc (Poteligeo®)

Mosunetuzumab-axgb (Lunsumio™, Lunsumio Velo™)

Motixafortide (Aphexda™)

M ultiple Sclerosis Products:(Ocrelizumab [Ocrevus™], Ocrelizumab and Hyaluronidase-ocsq [Ocrevus Zunovo™], Ublituximab-xiiy [Briumvi™])

Nadofaragene firadenovec-vncg (Adstiladrin®)

Narsoplimab-wuug (Yartemlea®)

Natalizumab (Tysabri®)

Naxitamab-gqgk (Danyelza®)

Necitumumab ((Portrazza®)

Nedosiran (Rivfloza™)

Nelarabine (Arranon®)

Nipocalimab-aahu (Imaavy™)

Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)

Nivolumab (Opdivo®)

Nivolumab/Relatlimab-rmbw (Opdualag™)

Nogapendekin Alfa-Inbakicept-pmln (Anktiva®)

Nusinersen (Spinraza®)

Obecabtagene Autoleucel (Aucatzyl®)

Obinutuzumab (Gazyva®)

Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension

Olipudase Alfa-rpcp (Xenpozyme™)

O malizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)

OnabotulinumtoxinA (Botox®)

Onasemnogene Abeparvovec-brve (Itvisma®)

Onasemnogene Abeparvovec-xioi (Zolgensma ®)

Paclitaxel (Protein-Bound) (Abraxane®)

Palivizumab (Synagis®)

Panitumumab (Vectibix®)

Pasireotide (Signifor® LAR)

Patisiran (Onpattro®)

Pegaspargase (Oncaspar®)

Pegcetacoplan (Syfovre™)

Pegfilgrastim (Neulasta®); Pegfilgrastim-jmdb (Fulphila®); Pegfilgrastim--pbbk (Fylnetra®); Pegfilgrastim- apgf (Nyvepria™); Pegfilgrastim-fpgk (Stimufed®); Pegfilgrastim-cbqv (Udenyca®); Pegfilgrastim-bmez (Ziextenzo™)

Pegloticase (Krystexxa®)

Pegunigalsidase Alfa-iwxj (Elfabrio®)

Pembrolizumab (Keytruda®)

Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)

Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU)

Pertuzumab (Perjeta®)

Pertuzumab Trastuzumab and Hyaluronidase-zzxf (Phesgo)

Polatuzumab Vedotin-piiq (Polivy™)

Pozelimab-bbfg (Veopoz®)

Plasminogen, human-tvmh (Ryplazim®)

Prademagene Zamikeracel (Zevaskyn™)

Pralatrexate (Folotyn®)

Ramucirumab (Cyramza®)

Ranibizumab (Lucentis®; Byooviz™)

Ranibizumab (Susvimo®)

Ravulizumab-cwvz (Ultomiris®)

Remestemcel-L-rknd (Ryoncil®)

Reslizumab (Cinqair®)

Revakinagene Taroretcel-lwey (Encelto™)

Retifanlimab-dlwr (Zynyz™)

RimabotulinumtoxinB (Myobloc®)

Risankizumab-rzaa (Skyrizi®)

Rituximab and Hyaluronidase Human Injection (Rituxan Hycela®)

Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Non-Oncology Indications)

Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Oncology Indications)

Romidepsin (Istodax®)

Romiplostim (Nplate®)

Romosozumab-aqqb (Evenity™)

Rozanolixizumab-noli (Rystiggo®)

Sacituzumab Govitecan-hziy (Trodelvy™)

Sargramostim (Leukine®)

Sebelipase Alfa (Kanuma™)

Secukinumab (Cosentyx®)

SCIG (Immune Globulin SQ)

Siltuximab (Sylvant™)

Sipuleucel-T (Provenge®)

Sirolimus protein-bound particles for injectable suspension (albumin-bound) (Fyarro™)

Sodium Thiosulfate (Pedmark®)

Sotatercept-csrk (WinrevairI™)

Spesolimab (Spevigo®)

Sutimlimab-jome (Enjaymo™)

Tafasitamab-cxix Monjuvi™)

Tagraxofusp-erzs (Elzonris™)

Taliglucerase Alfa (Elelyso® )

Talimogene Laherparepvec (Imlygic™)

Talquetamab-tgvs (Talvey™)

Tarlatamab-dlle (Imdelltra™)

Tebentafusp-tebn (Kimmtrak®)

Teclistamab-cqyv (Tecvayli™) (Subcutaneous)

Temozolomide for Injection (Temodar®)

Temsirolimus (Torisel®)

Teplizumab-mzwv (Tzield™)

Teprotumumab-trbw (Tepezza®)

Testosterone Pellets (Testopel®)

Tezepelumab-ekko (Tezspire™)

Thyrotropin Alfa (Thyrogen®)

Tildrakizumab-asmn (Ilumya™)

Tisagenlecleucel (Kymriah®)

Tislelizumab-jsgr (Tevimbra™)

Telisotuzumab vedotin-tllv (Emrelis™)

Tisotumab vedotin-tftv (Tivdak™)

Tocilizumab (Actemra®); Tocilizumab-bavi (Tofidence™)

Tofersen (Qalsody™)

Toripalimab-tpzi (Loqtorzi)

Trabectedin (Yondelis®)

Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta™

Trastuzumab Products (Herceptin®, Ontruzant®, Herzuma®, Ogivri®, Trazimera™, Kanjinti™, Hercessi™)

Travoprost Intracameral Implant (iDose TR®)

Tremelimumab-actl (Imjudo®)

Treprostinil injection (Remodulin®); Treprostinil

Triamcinolone Acetonide Injectable Suspension (Xipere®) (Suprachoroidal)

Trilaciclib (Cosela™)

Triptorelin (Triptodur®)

Triptorelin Pamoate (Trelstar®)

Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustenkinumab-ttwe; Ustekinumab-hmny (Starjemza)

Valoctocogene Roxaparvovec-rvox (Roctavian®)

Vedolizumab (Entyvio®)

Velaglucerase Alfa (Vpriv®)

Velmanase Alfa-tycv (Lamzede®)

Verteporfin (Visudyne®)

Vestronidase Alfa-vjbk (Mepsevii™)

Viltolarsen (Viltepso®)

Voretigene Neparvovec-rzyl (Luxturna®)

Vutrisiran (Amvuttra™)

Zanidatamab-hrii (Ziihera®)

Zenocutuzumab-zbco (Bizengri®)

Ziv-Aflibercept (Zaltrap®)

Zolbetuximab-clzb (Vyloy®)

Zoledronic Acid (Reclast®)

Zoledronic Acid (Zometa®)

Zopapogene Imadenovec-drba (Papzimeos™)

Zoster Vaccine Recombinant, Adjuvanted (Shingrix®)

This document has been classified as public information.