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Draft Medical
Policies |
BlueCross BlueShield of Tennessee works to ensure that Medical Policies are developed in an open, collaborative manner with our providers. We invite you to submit comments during the development phase of our Medical Policies.
Medical policies are developed using an evidence-based evaluation process. The medical evidence used in this process comes from several sources, including independent medical technology review organizations, the peer reviewed medical literature, and expert opinions from BCBST network specialists. We especially welcome comments that include this type of information. All Medical Policies are reviewed and approved by a panel of BCBST Medical Directors as well as board certified network physicians before final adoption by the company.
| Policy # | Policy Name | Date Posted | Date Removed |
| DMP1024-07 | Aducanumab-avwa | 10/21/24 | 11/21/24 |
| DMP1024-08 | C1 Esterase Inhibitor (Human) (Berinert) | 10/21/24 | 11/21/24 |
| DMP1024-09 | C1 Esterase Inhibitor (Human) (Cinryze) | 10/21/24 | 11/21/24 |
| DMP1024-10 | C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda) | 10/21/24 | 11/21/24 |
| DMP1024-11 | C1 Esterase Inhibitor( Recombinant) (Ruconest) | 10/21/24 | 11/21/24 |
| DMP1024-12 | Certolizumab Pegol | 10/21/24 | 11/21/24 |
| DMP1024-13 | Ecallantide | 10/21/24 | 11/21/24 |
| DMP1024-14 | Icatibant | 10/21/24 | 11/21/24 |
| DMP1024-15 | Inotuzumab Ozogamicin | 10/21/24 | 11/21/24 |
| DMP1024-16 | Lanadelumab-flyo | 10/21/24 | 11/21/24 |
| DMP1024-17 | Lecanemab-irmb | 10/21/24 | 11/21/24 |
| DMP1024-18 | Patisiran Lipid Complex | 10/21/24 | 11/21/24 |
| DMP1024-19 | Palivizumab | 10/21/24 | 11/21/24 |
| DMP1024-20 | Avelumab | 10/28/24 | 11/28/24 |
| DMP1024-21 | Bendamustine Products | 10/28/24 | 11/28/24 |
| DMP1024-22 | Brentuximab Vedotin | 10/28/24 | 11/28/24 |
| DMP1024-23 | Collagenase | 10/28/24 | 11/28/24 |
| DMP1024-24 | Corticotropin-ACTH: [HP Acthar Gel (repository corticotropin injection), Purified Cortrophin® Gel (repository corticotropin injection)] | 10/28/24 | 11/28/24 |
| DMP1024-25 | Crovalimab-akkz | 10/28/24 | 11/28/24 |
| DMP1024-26 | Donanemab-azbt | 10/28/24 | 11/28/24 |
| DMP1024-27 | Glofitamab-gxbm | 10/28/24 | 11/28/24 |
| DMP1024-28 | Inotersen | 10/28/24 | 11/28/24 |
| DMP1024-29 | Loncastuximab Tesirine-lpyl | 10/28/24 | 11/28/24 |
| DMP1024-30 | Rituximab Products (Non Oncology Indications) | 10/28/24 | 11/28/24 |
| DMP1024-31 | Rituximab Products (Oncology Indications) | 10/28/24 | 11/28/24 |
| DMP1024-32 | Rozanolixizumab-noli | 10/28/24 | 11/28/24 |
| DMP1024-33 | Teplizumab-mzwv | 10/28/24 | 11/28/24 |
| DMP1024-34 | Vutrisiran | 10/28/24 | 11/28/24 |
| DMP1024-35 | Protein Profiling Assays for Breast Cancer Prognosis | 10/29/24 | 11/29/24 |
| DMP1024-36 | Inebilizumab-cdon | 10/31/24 | 11/29/24 |
| DMP1024-37 | Tofersen | 10/31/24 | 11/29/24 |
| DMP1124-01 | Atezolizumab | 11/04/24 | 12/04/24 |
| DMP1124-02 | Next-generation sequencing for the assessment of measurable residual disease | 11/12/24 | 12/10/24 |
| DMP1124-03 | Atezolizumab and Hyaluronidase-tqjs | 11/12/24 | 12/10/24 |
| DMP1124-04 | Eculizumab Products | 11/12/24 | 12/10/24 |
| DMP1124-05 | Polatuzumab Vedotin-piiq | 11/12/24 | 12/10/24 |
| DMP1124-06 | Aldesleukin | 11/18/24 | 12/10/24 |
| DMP1124-07 | Benralizumab | 11/18/24 | 12/10/24 |
| DMP1124-08 | Edaravone | 11/18/24 | 12/10/24 |
| DMP1124-09 | Enfortumab Vedotin-ejfv | 11/18/24 | 12/10/24 |
| DP1124-10 | Isatuximab-irfc | 11/18/24 | 12/10/24 |
| DMP1124-11 | Pembrolizumab | 11/18/24 | 12/10/24 |
| DMP1124-12 | Sacituzumab Govitecan-hziy | 11/18/24 | 12/10/24 |
Please reference the policy name or tracking number in your comments.
To submit comments about the draft Pharmacy Policies:
Click the “Pharmacy Policy Comments” above or click here: Comments or Feedback.Please reference the policy name or tracking number in your comments.
To submit comments about the draft Medical Policies:
Click the “Medical Policy Comments” above or click here: Comments or Feedback.Comments can also be mailed to:
BlueCross BlueShield of Tennessee
Medical Policy
1 Cameron Hill Circle
Chattanooga, TN 37402