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 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 04/02/2025

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®)

Guselkumab (Tremfya®)

Zolbetuximab-clzb (Vyloy®)

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™)

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®)

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™)

Last Review Date: 1/14/2025