Draft Medical Policies BlueCross BlueShield of Tennessee

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
DMP0826-01	Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Afliberceptabzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])	08/6/26	09/6/26
DMP0826-02	Avalglucosidase Alfa-ngpt (Nexviazyme™)	08/6/26	09/6/26
DMP0826-03	Benralizumab (Fasenra®)	08/6/26	09/6/26
DMP0826-04	Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)	08/6/26	09/6/26
DMP0826-05	Brolucizumab-dbll (Beovu®)	08/6/26	09/6/26
DMP0826-06	Guselkumab (Tremfya®)	08/6/26	09/6/26
DMP0826-07	Ipilimumab (Yervoy®)	08/6/26	09/6/26
DMP0826-08	Leuprolide acetate (Eligard®, Vabrinty™)	08/6/26	09/6/26
DMP0826-09	Leuprolide Acetate (Fensolvi®)	08/6/26	09/6/26
DMP0826-10	Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)	08/6/26	09/6/26
DMP0826-11	Mirikizumab-mrkz (Omvoh)	08/6/26	09/6/26
DMP0826-12	Nivolumab (Opdivo®)	08/6/26	09/6/26
DMP0826-13	Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)	08/6/26	09/6/26
DMP0826-14	Pasireotide (Signifor® LAR)	08/6/26	09/6/26
DMP0826-15	Ranibizumab (Susvimo®)	08/6/26	09/6/26
DMP0826-16	Reslizumab (Cinqair®)	08/6/26	09/6/26
DMP0826-17	Risankizumab-rzaa (Skyrizi®)	08/6/26	09/6/26
DMP0826-18	Sebelipase Alfa (Kanuma®)	08/6/26	09/6/26
DMP0826-19	Triptorelin (Triptodur®)	08/6/26	09/6/26
DMP0826-20	Triptorelin Pamoate (Trelstar®)	08/6/26	09/6/26
DMP0826-21	Vedolizumab (Entyvio®)	08/6/26	09/6/26
DMP0826-22	Alglucosidase Alfa (Lumizyme®)	08/6/26	09/6/26
DMP0826-23	Agalsidase Beta (Fabrazyme®)	08/6/26	09/6/26
DMP0826-24	Amivantamab-vmjw (Rybrevant™)	08/6/26	09/6/26
DMP0826-25	Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro™)	08/6/26	09/6/26
DMP0826-26	Depemokimab-ulaa (Exdensur)	08/6/26	09/6/26
DMP0826-27	Faricimab-svoa (Vabysmo™)	08/6/26	09/6/26
DMP0826-28	Goserelin Acetate (Zoladex®)	08/6/26	09/6/26
DMP0826-29	Histrelin Acetate (Supprelin® LA)	08/6/26	09/6/26
DMP0826-30	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)	08/6/26	09/6/26
DMP0826-31	Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)	08/6/26	09/6/26
DMP0826-32	Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit)	08/6/26	09/6/26
DMP0826-33	Mepolizumab (Nucala®)	08/6/26	09/6/26
DMP0826-34	Nusinersen (Spinraza™)	08/6/26	09/6/26
DMP0826-35	Atidarsagene Autotemcel (LENMELDY™)	08/10/26	09/10/26
DMP0826-36	Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)	08/10/26	09/10/26
DMP0826-37	Pegunigalsidase Alfa-iwxj (Elfabrio®)	08/10/26	09/10/26
DMP0826-38	Tarlatamab-dlle (Imdelltra™)	08/10/26	09/10/26
DMP0826-39	Telisotuzumab vedotin-tllv (Emrelis™)	08/10/26	09/10/26
DMP0826-40	Testosterone Product: (Testosterone Pellets [Testopel®])	08/10/26	09/10/26
DMP0826-41	Tezepelumab-ekko (Tezspire®)	08/10/26	09/10/26
DMP0826-42	Toripalimab-tpzi (Loqtorzi)	08/10/26	09/10/26
DMP0826-43	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 ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza); ustekinumab-srlf	08/10/26	09/10/26
DMP0826-44	Allogeneic Regulatory T Cell Immunotherapy with HSPC and T cells-vldq (Tregzi™)	08/19/26	09/8/26
ID_CHS_56782026_1026	Teplizumab-mzwv (Tzield™)	08/27/26	09/27/26
ID_CHS_24132026a_0926	Benralizumab (Fasenra®)	08/27/26	09/27/26
ID_CHS_17002025_1026	Brentuximab Vedotin (Adcetris®)	08/27/26	09/27/26
ID_CHS_20042026_1026	Vedolizumab (Entyvio®)	08/27/26	09/27/26
ID_CHS_19762026a_1026	Ranibizumab (Lucentis®); Ranibizumab-nuna [Byooviz™]; Ranibizumab-eqrn [Cimerli™]; Ranibizumab-leyk [Nufymco™]; Ranibizumab-hkdz [Ranluspec®]	08/27/26	09/27/26
ID_CHS_20242026_1026	Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Aflibercept-abzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])	08/27/26	09/27/26
ID_CHS_18202026c_1026	Durvalumab (Imfinzi®)	08/27/26	09/27/26
ID_CHS_18942026a_1026	Nivolumab (Opdivo®)	08/27/26	09/27/26
ID_CHS_17962026a_1026	Ipilimumab (Yervoy®)	08/27/26	09/27/26
ID_CHS_67952026a_1026	Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)	08/27/26	09/27/26
ID_CHS_75422026_1026	Gedatolisib (Revtorpyk™)	08/27/26	09/27/26

 

Pharmacy Policy Comments:

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.

Medical Policy Comments:

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