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.

Tracking Number

Medical Policy Name

Beginning of Comment Period

End of Comment Period

DMP1118-25 C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®) 11/26/18 12/26/18
DMP1118-26 Icatibant 11/26/18 12/26/18
DMP1118-27 C1 Esterase Inhibitor (Ruconest®) 11/28/18 12/28/18
DMP1118-28 C1 Esterase Inhibitor (Cinryze®) 11/28/18 12/28/18
DMP1218-01 OnabotulinumtoxinA 12/05/18 01/05/19
DMP1218-02 Galsulfase 12/05/18 01/05/19
DMP1218-03 Olaratumab 12/05/18 01/05/19
DMP1218-04 AbobotulinumtoxinA 12/05/18 01/05/19
DMP1218-05 IncobotulinumtoxinA 12/06/18 01/06/19
DMP1218-06 RimabotulinumtoxinB 12/06/18 01/06/19
DMP1218-07 Browplasty 12/06/18 01/06/19
DMP1218-08 Tisagenlecleucel 12/06/18 01/06/19
DMP1218-09 Collagenase Clostridium Histolyticum 12/06/18 01/06/19
DMP1218-10 Gender Reassignment Surgery 12/06/18 01/06/19
DMP1218-11 Gemtuzumab Ozogamicin 12/07/18 01/07/19
DMP1218-12 Pegfilgrastim-cbqv 12/07/18 01/07/19
DMP1218-13 Levoleucovorin (Khapzory™) 12/07/18 01/07/19
DMP1218-14 Copanlisib 12/07/18 01/07/19


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