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 04/02/2025

Topics due to be included in the Medical Policy Manual on 04/30/2025

Topics due to be included in the Medical Policy Manual on 05/03/2025

Topics due to be included in the Medical Policy Manual on 05/31/2025

Topics due to be included in the Medical Policy Manual on 04/02/2025

Abatacept (Orencia®)

Atezolizumab (Tecentriq®)

Avelumab (Bavencio®)

Benralizumab (Fasenra®)

Betibeglogene autotemcel (Zynteglo®) (Intravenous)

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®

Blinatumomab (Blincyto®)

Brexucbtagene Autoleucel (Tecartus®)

Certolizumab Pegol (Cimzia®)

Crizanlizumab-tmca (Adakveo®)

DaxibotulinumtoxinA-lanm (Daxxify™)

Eflapegrastim-xnst (Rolvedon™)

Exagamglogene Autotemcel (Casgevy™)

Golimumab (Simponi ARIA®)

Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Connective Tissue Disorders

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™), Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), infliximab

Lovotibeglogene Autotemcel (Lyfgenia®)

Luspatercept-aamt (Reblozyl®)

Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)

Obinutuzumab (Gazyva®)

Onabotulinumtoxin A (Botox®)

Oral Negative Pressure Therapy Devices for The Treatment of Sleep Apnea

Pegfilgrastim (Neulasta®); Pegfilgrastim-jmdb (Fulphila®); Pegfilgrastim--pbbk (Fylnetra®); Pegfilgrastim- apgf (Nyvepria™); Pegfilgrastim—fpgk (Stimufed®); Pegfilgrastim-cbqv (Udenyca®); Pegfilgrastim-bmez (Ziextenzo™)

Sargramostim (Leukine®)

Tafasitamab-cxix (Monjuvi™)

Tisotumab Vedotin-tftv (Tivdak™)

Tocilizumab (Actemra®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®)

Tremelimumab-actl (Imjudo®)

Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™)

Topics due to be included in the Medical Policy Manual on 04/30/2025

Breast Reconstructive and Symmetry Surgery Following Mastectomy

Cetuximab (Erbitux®)

Durvalumab (Imfinzi®)

Low-Dose Radiotherapy for Non-Oncologic Indications

Nivolumab (Opdivo®)

Pegaspargase (Oncaspar®)

Pembrolizumab (Keytruda®)

Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU, Axtle™)

Ramucirumab (Cyramza®)

Tislelizumab-jsgr (TEVIMBRA™)

Medical Policies to be Archived on 05/03/2025

Implantable Hypoglossal Nerve Stimulation - This BCBST medical policy will be archived on May 3, 2025. The latest MCG Care Guideline for Hypoglossal Nerve Stimulation, Implantable ACG: A-0973 allows for broader coverage that is supported by quality medical evidence. The MCG Care Guideline may be viewed on 5/3/2025 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

These BCBST medical policies will be archived on May 3, 2025 in favor of transitioning over to using an available MCG guideline. The BCBST medical policy position and MCG guideline position is a close match; thus, there is no need to retain the BCBST medical policy. The MCG Care Guideline may be viewed on 5/3/2025 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Topics due to be included in the Medical Policy Manual on 05/31/2025

Ado-Trastuzumab Emtansine (Kadcyla®)

Certolizumab Pegol (Cimzia®)

Darbepoetin Alfa (Aranesp®)

Dostarlimab-gxly (Jemperli®)

Elapegademase-lvir (Revcovi®)

Epoetin Alfa Products (Epogen®, Procrit®, Retacrit®)

Epoprostenol for Continuous Intravenous Infusion (Flolan®/ Veletri®)

Fam-trastuzumab Deruxtecan-nxki (Enhertu®

Givosiran (Givlaari®)

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), infliximab

Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)

Onasemnogene Abeparvovec-xioi (Zolgensma®)

Sotatercept-csrk (WINREVAIR ™)

Tislelizumab-jsgr (TEVIMBRA™)

Trastuzumab Products: Trastuzumab (Herceptin®); Trastuzumab-dttb (Ontruzant®); Trastuzumabpkrb (Herzuma®); Trastuzumab-dkst (Ogivri®); Trastuzumab-qyyp (Trazimera™); Trastuzumabanns (Kanjinti™); Trastuzumab-strf (Hercessi™)

Treprostinil injection (Remodulin®); Treprostinil

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

Last Review Date: 3/3/2025

Medical Policy Comments:

Please reference the policy name in your comments.
To submit comments about the upcoming Medical policies:
Click the “Medical Policy Comments” above or click here: Comments or Feedback.

Pharmacy Policy Comments:

Please reference the policy name in your comments.
To submit comments about the upcoming Pharmacy policies:
Click the “Pharmacy 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