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
DMP0726-01	Eteplirsen (Exondys51™)	07/07/26	08/07/26
DMP0726-02	Eptinezumab-jjmr (Vyepti®)	07/07/26	08/07/26
DMP0726-03	Leuprolide Acetate (Fensolvi®)	07/07/26	08/07/26
DMP0726-04	Teprotumumab-trbw (Tepezza®)	07/07/26	08/07/26
DMP0726-05	Biofeedback and Neurofeedback	07/13/26	08/13/26
DMP0726-06	Pivekimab Sunirine-pvzy (Decnupaz™)	07/15/26	08/15/26
DMP0726-07	Ranibizumab (Lucentis®); Ranibizumab-nuna [Byooviz™]; Ranibizumab-eqrn [Cimerli™]; Ranibizumab-leyk [Nufymco™]; Ranibizumab-hkdz [Ranluspec®]	07/22/26	08/22/26
DMP0826-01	Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Afliberceptabzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])	08/6/26	09/6/26
DMP0826-02	Avalglucosidase Alfa-ngpt (Nexviazyme™)	08/6/26	09/6/26
DMP0826-03	Benralizumab (Fasenra®)	08/6/26	09/6/26
DMP0826-04	Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)	08/6/26	09/6/26
DMP0826-05	Brolucizumab-dbll (Beovu®)	08/6/26	09/6/26
DMP0826-06	Guselkumab (Tremfya®)	08/6/26	09/6/26
DMP0826-07	Ipilimumab (Yervoy®)	08/6/26	09/6/26
DMP0826-08	Leuprolide acetate (Eligard®, Vabrinty™)	08/6/26	09/6/26
DMP0826-09	Leuprolide Acetate (Fensolvi®)	08/6/26	09/6/26
DMP0826-10	Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)	08/6/26	09/6/26
DMP0826-11	Mirikizumab-mrkz (Omvoh)	08/6/26	09/6/26
DMP0826-12	Nivolumab (Opdivo®)	08/6/26	09/6/26
DMP0826-13	Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)	08/6/26	09/6/26
DMP0826-14	Pasireotide (Signifor® LAR)	08/6/26	09/6/26
DMP0826-15	Ranibizumab (Susvimo®)	08/6/26	09/6/26
DMP0826-16	Reslizumab (Cinqair®)	08/6/26	09/6/26
DMP0826-17	Risankizumab-rzaa (Skyrizi®)	08/6/26	09/6/26
DMP0826-18	Sebelipase Alfa (Kanuma®)	08/6/26	09/6/26
DMP0826-19	Triptorelin (Triptodur®)	08/6/26	09/6/26
DMP0826-20	Triptorelin Pamoate (Trelstar®)	08/6/26	09/6/26
DMP0826-21	Vedolizumab (Entyvio®)	08/6/26	09/6/26
DMP0826-22	Alglucosidase Alfa (Lumizyme®)	08/6/26	09/6/26
DMP0826-23	Agalsidase Beta (Fabrazyme®)	08/6/26	09/6/26
DMP0826-24	Amivantamab-vmjw (Rybrevant™)	08/6/26	09/6/26
DMP0826-25	Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro™)	08/6/26	09/6/26
DMP0826-26	Depemokimab-ulaa (Exdensur)	08/6/26	09/6/26
DMP0826-27	Faricimab-svoa (Vabysmo™)	08/6/26	09/6/26
DMP0826-28	Goserelin Acetate (Zoladex®)	08/6/26	09/6/26
DMP0826-29	Histrelin Acetate (Supprelin® LA)	08/6/26	09/6/26
DMP0826-30	Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg)	08/6/26	09/6/26
DMP0826-31	Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)	08/6/26	09/6/26
DMP0826-32	Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit)	08/6/26	09/6/26
DMP0826-33	Mepolizumab (Nucala®)	08/6/26	09/6/26
DMP0826-34	Nusinersen (Spinraza™)	08/6/26	09/6/26

 

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