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
DMP0625-31 Histrelin Acetate (Supprelin® LA) 06/12/25 07/12/25
DMP0625-32 Leuprolide Acetate (Fensolvi®) 06/12/25 07/12/25
DMP0625-33 Leuprolide Suspension (Lupron Depot-Ped®) 06/12/25 07/12/25
DMP0625-34 Omalizumab (Xolair®) 06/12/25 07/12/25
DMP0625-35 Triptorelin (Triptodur®) 06/12/25 07/12/25
DMP0625-36 Treatment for Sexual Dysfunction in Males: Non-pharmacologic 06/17/25 07/17/25
DMP0625-39 Prademagene Zamikeracel (Zevaskyn™) 06/26/25 07/26/25
DMP0625-40 Revakinagene Taroretcel-lwey (Encelto™) 06/26/25 07/26/25
DMP0625-41 Telisotuzumab vedotin-tllv (Emerlis™) 06/26/25 07/26/25
DMP0725-01 AbobotulinumtoxinA (Dysport®) 0710/25 08/10/25
DMP0725-02 Aflibercept Products: (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Aflibercept-abzv], Opuviz™
[Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])
0710/25 08/10/25
DMP0725-03 Atezolizumab (Tecentriq®) 0710/25 08/10/25
DMP0725-04 Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™) 0710/25 08/10/25
DMP0725-05 Bevacizumab Products: (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®) 0710/25 08/10/25
DMP0725-06 Cemiplimab-rwlc (Libtayo®) 0710/25 08/10/25
DMP0725-07 DaxibotulinumtoxinA-lanm (Daxxify™) 0710/25 08/10/25
DMP0725-08 Delandistrogene moxeparvovec-rokl (Elevidys®) 0710/25 08/10/25
DMP0725-09 Denosumab Products: Denosumab (Prolia®); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™);
Denosumab-bmwo (Stoboclo®); Denosumab-bnht (Conexxence®)
0710/25 08/10/25
DMP0725-10 Denosumab Products: Denosumab (Xgeva®); Denosumab-bnht (Bomyntra®); Denosumab-bmwo (Osenvelt®);
Denosumab-bbdz (Wyost®); Denosumab-dssb (Xbryk™)
0710/25 08/10/25
DMP0725-11 Eculizumab Products: (Soliris®, Bkemv™ [Eculizumab-aeeb], and Epysqli® [Eculizumab-aagh]) 0710/25 08/10/25
DMP0725-12 Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo) 0710/25 08/10/25
DMP0725-13 Fam-trastuzumab Deruxtecan-nxki (Enhertu®) 0710/25 08/10/25
DMP0725-14 IncobotulinumtoxinA (Xeomin®) 0710/25 08/10/25
DMP0725-15 Inebilizumab-cdon (Uplizna™) 0710/25 08/10/25
DMP0725-16 Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda
(Renflexis™); Infliximab-dyyb (Zymfentra), infliximab
0710/25 08/10/25
DMP0725-17 Ipilimumab (Yervoy®) 0710/25 08/10/25
DMP0725-18 Intravenous Immune Globulin (IVIG) 0710/25 08/10/25
DMP0725-19 Nivolumab (Opdivo®) 0710/25 08/10/25
DMP0725-20 Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™) 0710/25 08/10/25
DMP0725-21 Ocrelizumab (Ocrevus™) Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo) 0710/25 08/10/25
DMP0725-22 OnabotulinumtoxinA (Botox®) 0710/25 08/10/25
DMP0725-23 Pembrolizumab (Keytruda®) 0710/25 08/10/25
DMP0725-24 Pertuzumab (Perjeta®) 0710/25 08/10/25
DMP0725-25 RimabotulinumtoxinB (Myobloc®) 0710/25 08/10/25
DMP0725-26 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; ustekinumabaauz, ustekinumab-stba, ustekinumab-aekn ; ustenkinumab-ttwe 0710/25 08/10/25

 

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