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

DMP0718-03 Omaizumab (Xoliar) 07/18/18 08/18/18
DMP0718-04 Ocrelizumab 07/18/18 08/18/18
DMP0718-05 Natalizumb 07/18/18 08/18/18
DMP0718-06 Irinontecan Lipsome Injection 07/18/18 08/18/18
DMP0718-07 Octreotide Acetate Long-Acting Dosage Form 07/18/18 08/18/18
DMP0718-08 Magnetic Resonance Imaging (MRI) of the Breast 07/19/18 08/19/18
DMP0718-09 Brentuximab Vedotin 07/19/18 08/19/18
DMP0718-10 Free Testosterone Testing 07/19/18 08/19/18
DMP0718-11 Positron Emission Tomography (PET) for Miscellaneous Applications 07/20/18 08/20/18
DMP0718-12 Plasma Exchange 07/23/18 08/23/18
DMP0718-13 Tocilizumab (Intravenous) 07/25/18 - updated on 08/07/18 extended to 09/07/18
DMP0718-14 Vedolizumab 07/25/18 08/25/18
DMP0718-15 Tildrakizumab-asmn 07/25/18 - updated on 08/07/18 extended to 09/07/18
DMP0718-16 Certolizumab Pegol 07/25/18 08/25/18
DMP0718-17 Abatacept 07/25/18 - updated on 08/07/18 extended to 09/07/18
DMP0718-18 Laboratory Tests for Heart Transplant Rejection 07/31/18 08/31/18
DMP0818-01 Positron Emission Tomography (PET) for Cardiac Applications 08/01/18 09/01/18
DMP0818-02 Acupuncture 08/06/18 09/06/18
DMP0818-03 Positron Emission Tomography (PET) for Oncologic Applications 08/06/18 09/06/18
DMP0818-04 Pegfilgrastim-jmdb 08/06/18 09/06/18
DMP0818-05 Atezolizumab 08/06/18 09/06/18
DMP0818-06 Denosumab 08/06/18 09/06/18
DMP0818-07 Pembrolizumab
DMP0818-08 Fosnetupitant / Palonosetron 08/06/18 09/06/18
DMP0818-09 Daratumumab 08/08/18 09/08/18
DMP0818-10 Infliximab-abda 08/08/18 09/08/18
DMP0818-11 Epoetin Alfa-epbx 08/09/18 09/09/18
DMP0818-12 C1 Esterase Inhibitor (Cinryze®) 08/09/18 09/09/18
DMP0818-13 C1 Esterase Inhibitor Subcutaneous (Human) 08/09/18 09/09/18
DMP0818-14 Icatibant 08/09/18 09/09/18
DMP0818-15 Durvalumab 08/10/18 09/10/18
DMP0818-16 Levoleucovorin 08/13/18 09/13/18
DMP0818-17 Genetic Testing (CFTR mutations) for Cystic Fibrosis 08/13/18 09/13/18
DMP0818-18 BRCA1, BRCA2 and PALB2 Testing for Breast, Ovarian and Other Cancers 08/14/18 09/14/18
DMP0818-19 Golimumab for Intravenous Infusion 08/15/18 09/15/18
DMP0818-20 Pemetrexed 08/16/18 09/16/18
DMP0818-21 Ustekinumab 08/17/18 09/17/18


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