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
DMP0325-15	Home Nutritional Support (Total Parenteral / Enteral Nutrition)	03/17/25	04/17/25
DMP0325-16	Avacincaptad Pegol (Izervay™)	03/18/25	04/18/25
DMP0325-17	Mirikizumab-mrkz (Omvoh)	03/18/25	04/18/25
DMP0425-01	Remestemcel-L-rknd (Ryoncil®)	04/03/25	05/03/25
DMP0425-02	Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®)	04/07/25	05/07/25
DMP0425-03	Carfilzomib (Kyprolis®)	04/07/25	05/07/25
DMP0425-04	Cemiplimab-rwlc (Libtayo®)	04/07/25	05/07/25
DMP0425-05	Certolizumab Pegol (Cimzia®)	04/07/25	05/07/25
DMP0425-06	Denosumab Products: (Prolia®); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-bmwo (Stoboclo®)	04/07/25	05/07/25
DMP0425-07	Elivaldogene Autotemcel (Skysona®)	04/07/25	05/07/25
DMP0425-08	Evinacumab-dgnb (Evkeeza™)	04/07/25	05/07/25
DMP0425-09	Fidanacogene Elaparvovec-dzkt (Beqvez™)	04/07/25	05/07/25
DMP0425-10	Fluocinolone Acetonide Implant (Iluvien®)	04/07/25	05/07/25
DMP0425-11	Fosdenopterin (Nulibry™)	04/07/25	05/07/25
DMP0425-12	Guselkumab (Tremfya ®)	04/07/25	05/07/25
DMP0425-13	Nusinersen (Spinraza™)	04/07/25	05/07/25
DMP0425-14	Olipudase Alfa-rpcp (Xenpozyme™)	04/07/25	05/07/25
DMP0425-15	Retifanlimab-dlwr (Zynyz™)	04/07/25	05/07/25
DMP0425-16	Spesolimab-sbzo (Spevigo®)	04/07/25	05/07/25
DMP0425-17	Ttislelizumab-jsgr (Tevimbra™)	04/07/25	05/07/25
DMP0425-18	Valoctocogene Roxaparvovec-rvox (Roctavian®)	04/07/25	05/07/25
DMP0425-19	Vedolizumab (Entyvio®)	04/07/25	05/07/25
DMP0425-20	Velmanase Alfa-tycv (Lamzede®)	04/07/25	05/07/25
DMP0425-21	Zoledronic Acid (Reclast®)	04/07/25	05/07/25
DMP0425-22	Zoledronic Acid (Zometa®)	04/07/25	05/07/25
DMP0425-23	Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto®)	04/07/25	05/07/25
DMP0425-24	Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies	04/08/25	05/08/25
DMP0425-25	Negative Pressure Wound Therapy in the Outpatient Setting	04/15/25	05/15/25
DMP0425-26	Daratumumab (Darzalex®)	04/16/25	05/15/25
DMP0425-27	Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)	04/16/25	05/15/25
DMP0425-28	Inclisiran (Leqvio®)	04/16/25	05/15/25
DMP0425-29	Infliximab Products	04/16/25	05/15/25
DMP0425-30	Isatuximab-irfc (Sarclisa®)	04/16/25	05/15/25
DMP0425-31	Nivolumab/Relatlimab-rmbw (Opdualag™)	04/16/25	05/15/25
DMP0425-32	Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension	04/16/25	05/15/25
DMP0425-33	Risankizumab-rzaa (Skyrizi®)	04/16/25	05/15/25
DMP0425-34	Talimogene Laherparepvec (Imlygic™)	04/16/25	05/15/25
DMP0425-35	Ustekinumab Products	04/16/25	05/15/25

 

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