BlueCross BlueShield of Tennessee Medical Policy Manual

Pharmacology

View by Trade Name.

Abatacept (Orencia®)

Adalimumab (Humira®)

Agalsidase Beta (Fabrazyme®)

Aldesleukin (Systemic) (Proleukin®)

Alefacept (Amevive®)

Alemtuzumab (Campath®)

Alglucosidase Alfa (Myozyme®)

Alpha 1-Proteinase Inhibitor (Human) (Aralast®, Aralast NP, Prolastin® and Zemaira®)

Ambrisentan (Letairis®) for the Treatment of Pulmonary Hypertension

Aminocaproic Acid (Amicar®)

Anakinra (Kineret®)

Antihemophilic Factor (Factor VIII) (Adavate®, Alphanate® Plasma/Albumin Free Method, Helixate® FS, Hemofil® M Method M Monoclonal Purified, Humate-P®, Koate®-DVI, Kogenate® FS, Monarc-M® Method M Monoclonal Purified, Monoclate-P®, Recombinate®, ReFacto®, Xyntha™)

Anti-inhibitor Coagulant Complex (Autoplex-T®, FEIBA VH®)

Apomorphine Hydrochloride (Apokyn®)

Arsenic Trioxide (Trisenox®)

Autologous Chondrocyte Implantation

Azacitidine (Vidaza®)

Bendamustine (Treanda®)

Bevacizumab (Avastin®)

Bortezomib (Velcade®)

Bosentan (Tracleer®) for the Treatment of Pulmonary Hypertension

Botulinum Toxin (Botox®, Dysport®, Myobloc®)

C1 Esterase Inhibitor (Cinryze®)

Capecitabine (Xeloda®)

Carbogen (95% Oxygen, 5% Carbon Dioxide) Inhalation in Cancer Treatment

Certolizumab Pegol (Cimzia®)

Cetuximab (Erbitux®)

Chelation Therapy

Cidofovir (Vistide®)

Corticotropin Therapy (H.P. Acthar® Gel)

Cytochrome p450 Genotyping

Cytomegalovirus Immune Globulin Intravenous, Human (CMV-IGIV) (CytoGam®)

Dalteparin Sodium (Fragmin®)

Dasatinib (Sprycel®)

Decitabine (Dacogen™)

Deferasirox (Exjade®)

Desmopressin Acetate for Management of Hemorrhagic Episodes (DDAVP®, Stimate®)

Dofetilide for Atrial Fibrillation/Flutter (Tikosyn®)

Eculizumab (Soliris®)

Eltrombopag (Promacta®)

Enoxaparin Sodium (Lovenox®)

Epoprostenol Sodium (Flolan®) for the Treatment of Pulmonary Hypertension

Erectile Dysfunction - Pharmacological Response Test (PRT)

Erlotinib (Tarceva®)

Erythropoiesis-Stimulating Agents (ESAs) (Darbepoetin Alfa [Aranesp®], Epoetin Alfa [Epogen®, Procrit®])

Etanercept (Enbrel®)

Factor IX (AlphaNine® SD, Bebulin® VH, BeneFix®, Mononine®, Profilnine® SD, Proplex® T)

Factor VIIa (Recombinant) (NovoSeven®, NovoSeven® RT)

Fludarabine (Fludara®)

Fluocinolone Acetonide Intravitreal Implant (Retisert®)

Fondaparinux Sodium (Arixtra®)

Galsulfase (Systemic) (Naglazyme®)

Gefitinib (Iressa®)

Glatiramer Acetate (Copaxone®)

Glucocerebrosidase Enzyme Replenishers: Alglucerase (Ceredase®), Imiglucerase (Cerezyme®)

Goserelin Acetate (Zoladex®, Zoladex 3- month®, and Zoladex LA®)

Granulocyte Colony Stimulating Factors (G-CSFs) (Filgrastim, Neulasta®, Neupogen®, Pegfilgrastim)

Granulocyte-Macrophage Colony Stimulating Factors (GM-CSF) (Leukine®, Sargramostim)

Hepatitis B Immune Globulin (HepaGam®)

High Dose (Myeloablative) Chemotherapy with Bone Marrow, Peripheral Stem Cell, or Cord Blood Transplant for Hematopoietic Stem Cell Support

Histrelin Acetate Implant (Supprelin® LA, Vantas®)

Human Growth Hormone Replacement Therapy (Accretropin™, Genotropin®, Humatrope®, Norditropin®, Nutropin®, Saizen®, Serostim®, Tev-Tropin®, and Zorbtive®)

Human Papillomavirus (HPV) Vaccine (Gardasil®)

Hyaluronate Sodium (Euflexxa™, Hyalgan®, Orthovisc®, Supartz®, Synvisc®, and Synvisc-One™)

Ibritumomab Tiuxetan (Zevalin®)

Idursulfase (Elaprase®)

Iloprost for the Treatment of Pulmonary Hypertension (Ventavis®)

Imatinib Mesylate (Gleevec®)

Infliximab - Injectable (Remicade®)

Insulin Potentiation Therapy

Interferon Beta - 1a (Systemic) (Avonex®, Rebif®) and Interferon Beta - 1b (Systemic) (Betaseron®, Extavia®)

Interferon Gamma - 1b (Systemic) (Actimmune®)

Interferons Alfa (Systemic) (Alferon N®, Intron® A)

Intravenous Immune Globulin (IVIG) Therapy (Carimune NF, Gamimune, Gammagard SD, Gamunex, Flebogamma, Gammar-P, Iveegam, Panglobulin, Polygam SD, Privigen, Sandoglobulin and Venoglobulin)

Ixabepilone (Ixempra™)

Lanreotide Acetate (Somatuline® Depot)

Lapatinib (Tykerb®)

Laronidase (Aldurazyme®)

Lenalidomide (Revlimid®)

Leuprolide Acetate (Lupron®, Lupron Depot®, Lupron Depot-Ped®, Lupron Depot®-3 month, Lupron Depot®-4 month, Eligard®, Viadur®)

Mecasermin (rDNA origin) (Increlex®)

Methadone Detoxification for Opiate Addiction (Dolophine® Hydrochloride)

Miglustat (Zavesca®)

Mitoxantrone (Systemic) (Novantrone®)

Naltrexone (Vivitrol™, ReVia)

Natalizumab (Tysabri®)

Nilotinib (Tasigna®)

Octreotide (Systemic) (Sandostatin® and Sandostatin LAR® Depot)

Omalizumab (Xolair®)

Oprelvekin (Neumega®)

Paclitaxel (Protein-Bound) (Abraxane®)

Palivizumab (Synagis®)

Panitumumab (Vectibix®)

Pegaptanib Sodium (Macugen®)

Pegvisomant (Somavert®)

Pemetrexed (Alimta®)

Pharmaceutical Management of Chronic Hepatitis B (Intron® A, EpiVir® HBV, Pegasys®, Hepsera®, Baraclude®, Tyzeka®, Viread®)

Pharmaceutical Management of Chronic Hepatitis C (Copegus®, Infergen®, Intron® A, Pegasys®, Peg-Intron®, Rebetrol®, Rebetron®)

Photodynamic Therapy (PDT) for Conditions of the Eye

Photodynamic Therapy (PDT) for the Treatment of Actinic Keratoses

Photodynamic Therapy (PDT) for the Treatment of Cancer, including Barrett's Esophagus

Plerixafor (Mozobil™)

Posaconazole (Noxafil®)

Ranibizumab (Lucentis®) ®

Rho (D) Immune Globulins (Rhophylac®, WinRho® SDF)

Rilonacept (Arcalyst™)

Rituximab (Systemic) (Rituxan®)

Romiplostim (Nplate™)

Rotavirus Vaccine (RotaTeq®, Rotarix®)

Rufinamide (Banzel™)

Sapropterin (Kuvan™)

Sildenafil Citrate for the Treatment of Pulmonary Hypertension (Revatio®)

Sorafenib (Nexavar®)

Subcutaneous Immune Globulin (Vivaglobin®)

Sunitinib Malate (Sutent®)

Temozolomide (Temodar®)

Temsirolimus (Torisel™)

Teriparatide (Subcutaneous) (Forteo®)

Thalidomide (Thalomid®)

Tinzaparin Sodium (Innohep®)

Tositumomab (Bexxar®)

Trastuzumab (Herceptin®)

Treprostinil Sodium (Remodulin®) for the Treatment of Pulmonary Hypertension

Vorinostat (Zolinza®)

Zoledronic Acid (Zometa®, Reclast®)

Zoster Vaccine, Live (Zostavax®)

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