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


Serum Tumor Markers for Breast Malignancies

01/02/18 02/02/18


01/02/18 02/02/18
DMP0118-03 Carfilzomib 01/02/18 02/02/18
DMP0118-04 Treanda 01/02/18 02/02/18
DMP0118-05 Durvalumab 01/02/18 02/02/18


01/05/18 02/05/18
DMP0118-07 Brentuximab 01/05/18 02/05/18
DMP0118-08 Obinutuzumab 01/05/18 02/05/18

Prostatic Urethral Lift

01/05/18 02/05/18


01/19/18 02/19/18
DMP0118-11 Ustekinumab 01/22/18 02/22/18
DMP0118-12 Golimumab IV 01/22/18 02/22/18
DMP0118-13 RimabotulinumtoxinB 01/22/18 02/22/18
DMP0118-14 Ocriplasmin 01/22/18 02/22/18
DMP0118-15 Alpha-1 01/22/18 02/22/18
DMP0118-16 Vincristine Sulfate Liposome 01/22/18 02/22/18
DMP0118-17 Triptorelin Pamoate 01/22/18 02/22/18

Diagnosis and Treatment of Sacroiliac Joint Pain

01/22/18 02/22/18


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