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 9/1/2020

Topics due to be included in the Medical Policy Manual on 9/30/2020

Topics due to be included in the Medical Policy Manual on 10/31/2020

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Topics due to be included in the Medical Policy Manual on 9/1/2020:

Belimumab

Bortezomib(Velcade)

Bortezomib

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)

C1 Esterase Inhibitor (Human) (Cinryze®)

C1 Esterase Inhibitor (Recombinant) (Ruconest®)

Darbepoetin Alfa (Dialysis)

Darbepoetin Alfa (Non-Dialysis)

Epoetin Alfa (Dialysis)

Epoetin Alfa (Non-Dialysis)

Epoetin Alfa-epbx (Dialysis)

Epoetin Alfa-epbx (Non-Dialysis)

Inebilizumab

Ipilimumab

Irinotecan Liposome Injection

Leuprolide Acetate for Depot Suspension

Lurbinectedin

Methoxy Polyethylene Glycol-Epoetin Beta (Dialysis)

Methoxy Polyethylene Glycol-Epoetin Beta (Non Dialysis)

Nivolumab (Intravenous)

Octreotide Acetate Long-Acting Dosage Form

Ofatumumab

Ovarian Cancer Tumor Markers

Percutaneous Vertebroplasty, Kyphoplasty, and Mechanical Vertebral Augmentations

Talimogene Laherparepvec

Temsirolimus

Treatments for Athletic Groin Pain

Topics due to be included in the Medical Policy Manual on 9/30/2020:

Abatacept

AbobotulinumtoxinA

Alpha-1-Proteinase Inhibitor Therapy

Azacitidine

Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Rhinosinusitis

Bevacizumab Biosimilar Products for the Treatment of Neoplastic Disease

Bevacizumab for the Treatment of Neoplastic Disease

Certolizumab Pegol

Denosumab

Dexamethasone Intravitreal Implant

Fluocinolone Acetonide Intravitreal Implant for the Treatment of Uveitis (Retisert®)

Fluocinolone Acetonide Intravitreal Implant (Yutiq™)

Gemcitabine in Sodium Chloride Injection

Goserelin Acetate Implant

Ibalizumab-uiyk

IncobotulinumtoxinA

Isatuximab-irfc

Nusinersen

OnabotulinumtoxinA

Onasemnogene Abeparvovec-xioi

RimabotulinumtoxinB

Rituximab and Hyaluronidase Human Injectionacept

Rituximab Biosimilar Products

Rituximab

Romosozumab-aqqg

Trabectedin

Trastuzumab Biosimilar Products

Trastuzumab and Hyaluronidase-oysk

Trastuzumab

To be Archived on 9/30/2020:

Topics due to be included in the Medical Policy Manual on 10/31/2020:

Ado-Trastuzumab Emtansine

Atezolizumab

Avelumab

Blinatumomab

Bortezomib (Intravenous Only)

Bortezomib (Velcade)

Brentuximab Vedotin

Cetuximab

Eribulin Mesylate

Fam-trastuzumab Deruxtecan-nxki

Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema (Iluvien)

Obinutuzumab

Paclitaxel (Protein-Bound Particles)

Polatuzumab Vedotin-piiq

Transpupillary Thermotherapy (TTT)

Triptorelin Pamoate


Last Review Date: 8/11/2020

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.

Comments can also be mailed to:

BlueCross BlueShield of Tennessee
Medical Policy
1 Cameron Hill Circle
Chattanooga, TN 37402