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 04/30/2021

Medical Policies to be Archived on 5/8/2021

Topics due to be included in the Medical Policy Manual on 06/02/2021

Topics due to be included in the Medical Policy Manual on 06/30/2021

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Topics due to be included in the Medical Policy Manual on 04/30/2021:

Abatacept (Intravenous)

Atezolizumab

Avelumab

Brentuximab Vedotin

Certolizumab Pegol

Durvalumab

Home Nutritional Support (Total Parenteral / Enteral Nutrition)

Onasemnogene Abeparvovec-xioi

Paclitaxel (Protein-Bound Particles)

Pegfilgrastim Biosimilar Products

Pembrolizumab

Rituximab Biosimilar Products

Trabectedin

Trastuzumab and Hyaluronidase-oysk

Trastuzumab Biosimilar Products

Trastuzumab

Trilaciclib (Cosela™)

Medical Policies to be Archived on 5/8/2021:

Sublingual Liquid Immunotherapy - BCBST will be archiving this medical policy effective May 8, 2021 and transition over to the 25th edition MCG Care Guideline titled Sublingual Immunotherapy (A-0430). The MCG Care Guideline may be viewed on 5/8/2020 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension - BCBST will be archiving this medical policy effective May 8, 2021 and transition over to the new 25th edition MCG Care Guideline titled Renal Sympathetic Nerve Ablation, Radiofrequency (ACG: A-1034). The new MCG Care Guideline aligns with the current BCBST medical policy and may be viewed on 5/8/2020 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer - BCBST will be archiving this medical policy effective May 8, 2021 and transition over to utilizing the MCG Care Guidelines. These three MCG Care Guidelines can be viewed by using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Topics due to be included in the Medical Policy Manual on 06/02/2021:

Ado-Trastuzumab Emtansine (Kadcyla®)

Aldesleukin (Proleukin®)

Belimumab (Benlysta®)

Bevacizumab Products for the Treatment of Neoplastic Disease (Avastin®, bevacizumab-awwb [Mvasi®] and bevacizumab-bvzr [Zirabev™])

Breast Cancer Gene Expression Assays

Cetuximab (Erbitux®)

Crizanlizumab-tmca (Adakveo®)

Emapalumab-lzsg (Gamifant™)

Epoprostenol for Continuous Intravenous Infusion (Flolan®/ Veletri®)

Fam-Trastuzumab Deruxtecan-nxki (Enhertu®)

Givosiran (Givlaari®)

Idursulfase (Elaprase®)

IncobotulinumtoxinA (Xeomin®)

Laronidase (Aldurazyme®)

Nelarabine (Arranon®)

Nivolumab (Opdivo®) (Intravenous)

Omalizumab (Xolair®)

Pemetrexed (Alimta®)

Pertuzumab (Perjeta®)

Pralatrexate (Folotyn®)

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

Romiplostim (Nplate®)

Siltuximab (Sylvant™)

Teprotumumab-trbw (Tepezza®)

Thyrotropin Alfa (Thyrogen®)

Treprostinil for Continuous Subcutaneous/Intravenous Infusion (Remodulin®)

Vincristine Sulfate Liposome Injection (Marqibo®)

Voretigene Neparvovec-rzyl (Luxturna®)

Topics due to be included in the Medical Policy Manual on 06/30/2021:

Belantamab Mafodotin-blmf (Blenrep®)

Benralizumab (Fasenra®)

Blinatumomab (Blincyto®)

Bortezomib (Intravenous Only)

Bortezomib (Velcade®)

Carfilzomib (Kyprolis®)

Cemiplimab-rwlc (Libtayo®)

Elosulfase Alfa (Vimizim®)

Eribulin Mesylate (Halaven®)

Human Amniotic Membrane Grafts and Amniotic Fluid Injections

Levoleucovorin (Fusilev™, Khapzory®)

Noninvasive Techniques for Evaluation and Monitoring of Chronic Liver Diseases

OnabotulinumtoxinA (Botox®)

Pembrolizumab (Keytruda®)


Last Review Date: 4/14/2021

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