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
DMP0125-03	Epoprostenol for Continuous Intravenous Infusion (Flolan®/Veletri®)	01/23/25	02/23/25
DMP0125-04	Sotatercept-csrk (Winrevair™)	01/23/25	02/23/25
DMP0125-15	Treprostinil injection (Remodulin®); Treprostinil	01/23/25	02/23/25
DMP0225-01	Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)	02/06/25	03/06/25
DMP0225-02	Ado-Trastuzumab Emtansine (Kadcyla®)	02/10/25	03/10/25
DMP0225-03	Certolizumab Pegol (Cimzia®)	02/10/25	03/10/25
DMP0225-04	Darbepoetin Alfa (Aranesp®)	02/10/25	03/10/25
DMP0225-05	Dostarlimab-gxly (Jemperli®)	02/10/25	03/10/25
DMP0225-06	Elapegademase-lvir (Revcovi®)	02/10/25	03/10/25
DMP0225-07	Epoetin Alfa Products (Epogen®, Procrit®, Retacrit®)	02/10/25	03/10/25
DMP0225-08	Fam-trastuzumab Deruxtecan-nxki (Enhertu®)	02/10/25	03/10/25
DMP0225-09	Givosiran (Givlaari®)	02/10/25	03/10/25
DMP0225-10	Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™), Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), infliximab	02/10/25	03/10/25
DMP0225-11	Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)	02/10/25	03/10/25
DMP0225-12	Onasemnogene Abeparvovec-xioi (Zolgensma®)	02/10/25	03/10/25
DMP0225-13	Tislelizumab-jsgr (TEVIMBRA™)	02/10/25	03/10/25
DMP0225-14	Trastuzumab Products: Trastuzumab (Herceptin®); Trastuzumab-dttb (Ontruzant®); Trastuzumabpkrb (Herzuma®); Trastuzumab-dkst (Ogivri®); Trastuzumab-qyyp (Trazimera™); Trastuzumabanns (Kanjinti™); Trastuzumab-strf (Hercessi™)	02/10/25	03/10/25
DMP0225-15	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™); ustekinumabaekn	02/10/25	03/10/25
DMP0225-16	Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine)	02/19/25	03/19/25
DMP0225-17	C1 Esterase Inhibitor (Human) (Berinert®)	02/19/25	03/19/25
DMP0225-18	C1 Esterase Inhibitor (Human) Cinryze®)	02/19/25	03/19/25
DMP0225-19	C1 Esterase Inhibitor (recombinant) (Ruconest®)	02/19/25	03/19/25
DMP0225-20	C1 Esterase Inhibitor Subcutaneous (Human) Haegarda®	02/19/25	03/19/25
DMP0225-21	Ecallantide (Kalbitor®)	02/19/25	03/19/25
DMP0225-22	Icatibant (Firazyr®), Icatibant (Sajazir™), Icatibant	02/19/25	03/19/25
DMP0225-23	Lanadelumab-flyo (Takhzyro®)	02/19/25	03/19/25
DMP0225-24	Mosunetuzumab-axgb (Lunsumio™)	02/19/25	03/19/25
DMP0225-25	Zenocutuzumab-zbco (Bizengri®)	02/19/25	03/1925

 

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