BlueCross BlueShield of Tennessee Medical Policy Manual

Specialty Medications by Trade Name

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Abraxane®

Actemra®

Acthar® Gel - H.P.

Adagen®

Adcetris®

Aldurazyme®

Alimta®

Aliqopa®

Aloxi®

Aralast®-NP

Aranesp®

Arranon®

Arzerra®

Avastin®

Bavencio®

Beleodaq®

Bendeka®

Benlysta®

Berinert®

Besponsa™

Bivigam®

Blincyto®

Botox®

Brineura

Carimune® NF

Cerezyme®

Cervarix®

Cimzia®

Cinqair®

Cinryze®

Cuvitru®

Cyramza®

Darzalex

Durolane®

Dysport®

Elaprase®

Elelyso®

Eligard®

Empliciti™

Entyvio®

Epogen®

Erbitux®

Euflexxa®

Exondys 51™

Eylea®

Fabrazyme®

Fasenra®

Firmagon®

Flebogamma® 5% DIF/Flebogamma® 10% DIF

Flolan®

Folotyn®

Fusilev®

Gammagard® S/D / Gammagard® Liquid (Intravenous)

Gammagard® Liquid (Subcutaneous)

Gammaked® (Intravenous)

Gammaked® (Subcutaneous)

Gammaplex®

Gamunex®-C (Intravenous)

Gamunex®-C (Subcutaneous)

Gardasil® / Gardasil® 9

Gazyva®

Gel-One®

Gel-Syn™

GenVisc® 850

Glassia®

H.P. Acthar® Gel

Halaven®

Herceptin®

Hizentra®

Hyalgan®

Hymovis®

HyQvia®

Ilaris®

Iluvien®

Imfinzi

Imlygic ®

Inflectra®

Istodax®

Ixempra®

Jetrea®

Jevtana®

Kadcyla®

Kalbitor®

Kanuma

Keytruda®

Krystexxa®

KYMRIAH™

Kyprolis®

Lartruvo ®

Lemtrada®

Letairis™

Leukine®

Lucentis®

Lumizyme®

Lupron Depot® / Lupron Depot-Ped®

Luxturna™

Macugen®

Marqibo®

Mepsevii

Mircera®

Monovisc®

Mylotarg™

Myobloc®

Naglazyme®

Neulasta®

Nplate®

Nucala®

Ocrevus

Octagam® 5% / Octagam® 10%

Onivyde™

Opdivo®

Orencia®

Orenitram™

Orthovisc®

Ozurdex®

Perjeta®

Photofrin®

Portrazza®

Privigen®

Procrit®

Prolastin®-C

Proleukin®

Prolia®

Provenge®

Radicava®

Reclast®

Remicade®

Remodulin®

Renflexis™

Retisert®

Revatio™

Rituxan®

Rituxan Hycela™

Ruconest®

Sandostatin® LAR Depot

Shingrix®

Signifor® LAR

Simponi Aria®

Soliris®

Somatuline® Depot

Spinraza™

Stelara®

Supartz®/Supartz® FX

Supprelin® LA

Sustol®

Sylvant ®

Synagis®

Synribo®

Synvisc®, Synvisc®-One

Tecentriq ®

Temodar®

Testopel®

Thyrogen®

Torisel®

Tracleer®

Treanda®

Trelstar®

Triptodur™

TriVisc™

Tysabri®

Tyvaso®

Vantas®

Vectibix®

Velcade®

Veletri®

Ventavis®

Vidaza®

Vimizim®

Visco-3®

Visudyne®

Vpriv®

VYXEOS™

Xeloda®

Xeomin®

Xgeva®

Xiaflex®

Xolair®

Yervoy®

Yescarta™

Yondelis®

Zaltrap®

Zemaira®

Zoladex®

Zometa®

Zostavax®