BlueCross BlueShield of Tennessee Medical Policy Manual

Specialty Medications by Trade Name

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Abecma®

Abraxane®

Actemra®

Acthar® Gel - H.P.

Adakveo

Adcetris®

Adstiladrin®

Aduhelm™

Adzynma

Aldurazyme®

Alimta®

Alyglo™

Alymsys

Amondys 45™

Amtagvi

Amvuttra™

Anktiva®

Aphexda™

Aralast®-NP

Aranesp®

Arranon®

Asceniv™

Asparlas®

Avastin®

Avsola™

Avzivi®

Bavencio®

Beleodaq®

Belrapzo™

Bendeka®

Benlysta®

Beovu®

Beqvez™

Berinert®

Besponsav®

Bivigam®

Blincyto®

Botox®

Breyanzi®

Brineura®

Briumvi™

Byooviz™

Camcevi™

Carvyktil

Casgevy™

Cerezyme®

Cimerli™

Cimzia®

Cinqair®

Cinryze®

Columvi™

Cortrophin® Gel

Cosela™

Cosentyx®

Crysvita®

Cutaquig®

Cuvitruv®

Cyramza®

Danyelzav®

Darzalex®

Darzalex Faspro®

Daxxify™

Durolane®

Dysport®

Elahere™

Elaprase®

Elelyso®

Elevidys®

Elfabrio®

Eligard®

Elrexfio™

Elzonris™

Empliciti™

Enjaymo™

Epkinly™

Epogen®

Erbitux®

Euflexxa®

Evenity™

Evkeeza

Exondys 51™

Eylea®; Eylea®HD

Fabrazyme®

Fasenra®

Fensolvi®

Firazyr®

Firmagon®

Flebogamma® DIF

Flolan®

Folotyn®

Fulphila®

Fusilev®

Fyarro™

Fylnetra®

Gamifant™

Gammagard® S/D

Gammagard® Liquid

Gammaked®

Gammaplex®

Gamunex®-C

Gazyva®

Gel-One®

Gel-Syn™

GenVisc® 850

Givlaari™

Glassia®

H.P. Acthar® Gel

Haegarda®

Halaven®

Hemgenix®

Herceptin Hylecta™

Herceptin®

Hercessi™
Herzuma®

Hizentra®

HP Acthar Gel (repository corticotropin injection)

Hyalgan®

Hymovis®

HyQvia®

iDose TR®

Ilaris®

Ilumya™

Iluvien®

Imdelltra™

Imfinzi®

Imjudo®

Imlygic™

Inflectra™

Istodax®

Ixempra®

Izervay™

Jelmyto™

Jemperli®

Jevtana®

Kadcyla®

Kalbitor®

Kanjinti™

Kanuma

Keytruda®

Khapzory™

Kimmtrak®

Kisunla™

Krystexxa®

Kymriah®

Kyprolis®

Lamzede®

Libtayo®

Lemtrada®

Lenmeldy™

Leqembi™

Leqvio®

Leukine®

Loqtorzi

Lucentis®

Lumizyme®

Lunsumio™

Lupron Depot®, Leuprolide Acetate Depot #1

Lupron Depot®, Leuprolide Acetate Depot #2

Lutrate Depot™

Luxturna®

Lyfgenia®

Margenza™

Mepsevii

Mircera®

Monjuvi

Monovisc®

MVASI®

Mylotarg™

Myobloc®

Naglazyme®

Nexviazyme™

Neulasta®

Nplate®

Nulibry™

Nucala®

Nyvepria™

Ocrevus

Ocrevus Zunovo™

Octagam® 5% / Octagam® 10%

Ogivri®

Omvoh

Oncaspar®

Onivyde™
Onpattro®

Ontruzant®

Opdivo®

Opdualag™

Orencia®

Orthovisc®

Oxlumo®

Ozurdex®

Padcev

Pedmark®

Pemrydi RTU

Perjeta®

Phesgo

Polivy™

Pombiliti™

Poteligeo®

Privigen®

Procrit®

Prolastin®-C

Proleukin®

Prolia®

Provenge®

Qalsody™

Reblozyl®

Radicava®

Reclast®

Remicade®

Remodulin®

Renflexis®

Retacrit®

Rethymic®

Retisert®

Revcovi™

Riabni™ (Non-Oncology Indications)

Riabni™ (Oncology Indications)

Rituxan® (Non-Oncology Indications)

Rituxan® (Oncology Indications)

Rituxan Hycela®

Rivfloza™

Roctavian®

Rolvedon™

Ruconest®

Ruxience® (Non-Oncology Indications)

Ruxience® (Oncology Indications)

Rybrevant™

Rylaze™

Ryplazim®

Rystiggo®

Rytelo™

Sandostatin® LAR

Saphnelo™

Sarclisa®

Shingrix®

Signifor® LAR

Simponi Aria®

Skyrizi®

Skysona®

Soliris®

Somatuline® Depot

Spevigo®

Spinraza®

Stelara®

Stimufed®)

Supartz®/Supartz® FX

Supprelin® LA

Syfovre™

Sylvant®

Synagis®

Synojoynt

Synvisc®, Synvisc®-One

Takhzyro®

Talvey™

Tecartus™

Tecelra®

Tecentriq®

Tecentriq Hybreza™

Tecvayli™

Tegsedi™

Temodar®   

Tepezza®

Testopel®

Tevimbra™

Tezspire™

Thyrogen®

Tivdak™

Tofidence™

Torisel®

Treanda®

Trelstar®

Triptodur®

TriVisc™

Trodelvy™

Trogarzo™

Trazimera

Triptodur®

Tremfya®

Truxima® (Non-Oncology Indications)

Truxima® (Oncology Indications)

Tysabri®

Udenyca®

Ultomiris®

Vabysmo™

Vectibix®

Veklury®

Velcade®

Veletri®

Veopoz®

Viltepso

Vidaza®

Vimizim®

Visco-3®

Visudyne®

Vivimusta™

Vpriv®

Vyepti®

Vyjuvek™

Vyloy®

Vyondys

Vyvgart™

Vyvgart®Hytrulo

Vyxeos®

WinrevairI™

Wezlana™

Xembify®

Xenpozyme™

Xeomin®

Xgeva®

Xiaflex®

Xipere®

Xolair®

Yervoy®

Yescarta™

Yimmugo®

Yondelis®

Yutiq®

Zaltrap®

Zemaira®

Ziextenzo™

Zirabev™

Zoladex®

Zometa®

Zolgensma®

Zynlonta™

Zynteglo®

Zynyz™