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 05/01/2026

Topics due to be included in the Medical Policy Manual on 05/02/2026

Topics due to be included in the Medical Policy Manual on 06/02/2026

Topics due to be included in the Medical Policy Manual on 06/30/2026

Topics due to be included in the Medical Policy Manual on 07/01/2026

Topics due to be included in the Medical Policy Manual on 05/01/2026

Commercial BlueCare PAD Step Therapy Guide

Medical Policies to be Archived on 05/02/2026

Topics due to be included in the Medical Policy Manual on 06/02/2026

Ado-Trastuzumab Emtansine (Kadcyla®)

Burosumab-twza (Crysvita®)

Darbepoetin Alfa (Aranesp®)

Dostarlimab-gxly (Jemperli®)

Enfortumab Vedotin-ejfv (Padcev®)

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

Fam-trastuzumab Deruxtecan-nxki (Enhertu®)

Givosiran (Givlaari®)

Infliximab Products

Irinotecan Liposome Injection (Onivyde®)

Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)

Mirvetuximab Soravtansine-gynx (Elahere™)

Mosunetuzumab-axgb (Lunsumio™, Lunsumio Velo™)

Orthoptic Training for the Treatment of Vision or Learning Disabilities

Trabectedin (Yondelis®)

Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta™)

Trastuzumab Products

Topics due to be included in the Medical Policy Manual on 06/30/2026

Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Afliberceptabzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])

Atezolizumab (Tecentriq®)

Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)

Corneal Collagen Cross-Linking

Denosumab Products: (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); enosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-bmwo (Stoboclo®)

Denosumab Products: (Xgeva®); Denosumab-kyqq (Aukelso™); Denosumab-nxxp (Bilprevda®); Denosumab-bnht (Bomyntra®); Denosumab-bmwo Osenvelt®); Denosumab-bbdz (Wyost®); Denosumab-dssb (Xbryk™), Denosumab-qbde (Xtrenbo™)

Durvalumab (Imfinzi®)

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

Fam-trastuzumab Deruxtecan-nxki (Enhertu®)

Inebilizumab-cdon (Uplizna™)

Intravenous Immune Globulin (IVIG) - Alyglo™ (Immune Globulin Intravenous (Human)-stwk) Asceniv™ (Immune Globulin Intravenous (Human) - slra); Bivigam®; Flebogamma® DIF; Gammagard® Liquid; Gammagard® Liquid ERC; Gammagard® S/D; Gammaked™; Gammaplex®; Gamunex®-C; Octagam®; Panzyga ® (Immune Globulin Intravenous (Human) - ifas); Privigen®; Qivigy® (Immune Globulin Intravenous (Human) - kthm); Yimmugo® (Immune Globulin Intravenous (Human) - dira)

Luspatercept-aamt (Reblozyl®)

Nivolumab (Opdivo®)

Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)

Onasemnogene Abeparvovec-xioi (Zolgensma®)

Pembrolizumab (Keytruda®)

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

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

Tezepelumab-ekko (Tezspire®)

Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta™)

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

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™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza)

Topics due to be included in the Medical Policy Manual on 07/01/2026

Commercial BlueCare PAD_Step Therapy Guide

Last Review Date: 4/30/2026

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