Upcoming Medical Policies BlueCross BlueShield of Tennessee

Each medical policy listed below will become effective on the date indicated, and will be included in the Medical Policy Manual for BlueCross BlueShield of Tennessee on that effective date.

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 opinions from appropriate network specialists. All Medical Policies are reviewed by a panel of internal and external physicians before being adopted by the company.

Topics due to be included in the Medical Policy Manual on 12/31/2024

Topics due to be included in the Medical Policy Manual on 01/30/2025

Topics due to be included in the Medical Policy Manual on 03/04/2025

Topics due to be included in the Medical Policy Manual on 12/31/2024:

Daunorubicin and Cytarabine, Liposome (Vyxeos®)

Etranacogene Dezaparvovec-drlb (Hemgenix®)

Goserelin Acetate (Zoladex®)

Leuprolide acetate (Eligard®)

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)

Nelarabine (Arranon®)

Radiofrequency Ablation for Nasal Obstruction and Rhinitis

Testosterone Pellets (Testopel®)

Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)

Donanemab-azbt (Kisunla™)

Pharmacy Policies to be Archived on 12/31/2024:

Copanlisib (Aliqopa®) - BCBST plans to archive this pharmacy policy on 12/31/2024.

Moxetumomab pasudotox-tdfk (Lumoxiti®) -  BCBST plans to archive this pharmacy policy on 12/31/2024.

Omacetaxine Mepesuccinate (Synribo®) -  BCBST plans to archive this pharmacy policy on 12/31/2024.

Topics due to be included in the Medical Policy Manual on 01/30/2025

Amivantamab-vmjw (Rybrevant™)

Bortezomib (Velcade®; Bortezomib, Boruzu™)

Delandistrogene moxeparvovec-rokl (Elevidys®)

Topics due to be included in the Medical Policy Manual on 03/04/2025

Step Therapy Requirements for Provider Administered Specialty Medications

Aducanumab-avwa (Aduhelm™)

Aldesleukin (Proleukin®)

Atezolizumab (Tecentriq®)

Avelumab (Bavencio®)

Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine)

Benralizumab (Fasenra®)

Brentuximab Vedotin (Adcetris®)

C1 Esterase Inhibitor (Human) Cinryze®

C1 Esterase Inhibitor (recombinant) (Ruconest®)

C1 Esterase Inhibitor Subcutaneous (Human) Haegarda®

C1 Esterase Inhibitor (Human) (Berinert®)

Certolizumab Pegol (Cimzia®)

Collagenase Clostridium Histolyticum (Xiaflex®)

Corticotropin-ACTH: [HP Acthar Gel (repository corticotropin injection), Purified Cortrophin® Gel (repository corticotropin injection)]

Crovalimab-akkz (Piasky®)

Ecallantide (Kalbitor®)

Eculizumab Products (Soliris®, Bkemv™ [Eculizumab-aeeb], and Epysqli® [Eculizumab-aagh])

Edaravone (Radicava®)

Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo)

Enfortumab Vedotin-ejfv (Padcev®)

Glofitamab-gxbm (Columvi™)

Icatibant (Firazyr®), Icatibant (Sajazir™), Icatibant

Inebilizumab-cdon (Uplizna™)

Inotersen (Tegsedi™)

Inotuzumab Ozogamicin (Besponsa™)

Isatuximab-irfc (Sarclisa®)

Lanadelumab-flyo (Takhzyro®)

Lecanemab-irmb (Leqembi™)

Loncastuximab Tesirine-lpyl (Zynlonta®)

Next-Generation Sequencing for the Assessment of Measurable Residual Disease

Palivizumab (Synagis®)

Patisiran Lipid Complex (Onpattro®)

Pembrolizumab (Keytruda®)

Polatuzumab Vedotin-piiq (Polivy®)

Protein Profiling Assays for Breast Cancer Prognosis

Ravulizumab-cwvz (Ultomiris®)

Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®], Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Non-Oncolgy Indications)

Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®], Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Oncology Indications)

Rozanolixizumab-noli (Rystiggo®)

Sacituzumab Govitecan-hziy (Trodelvy®)

Teplizumab-mzwv (Tzield™)

Tofersen (Qalsody™)

Vutrisiran (Amvuttra™)

Last Review Date: 12/12/2024