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 10/31/2024

Topics due to be included in the Medical Policy Manual on 12/03/2024

Topics due to be included in the Medical Policy Manual on 12/31/2024

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Topics due to be included in the Medical Policy Manual on 10/31/2024:

Abatacept (Orencia®)

Cemiplimab-rwlc (Libtayo®)

Certolizumab Pegol (Cimzia®)

Delandistrogene moxeparvovec-rokl (Elevidys®)

Durvalumab (Imfinzi®)

Fam-trastuzumab Deruxtecan-nxki (Enhertu®)

Golimumab (Simponi ARIA®)

Inclisiran (Leqvio®)

Infliximab Products

Lisocabtagene Maraleucel (Breyanzi®)

Mirikizumab-mrkz (Omvoh)

Pembrolizumab (Keytruda®)

Risankizumab-rzaa (Skyrizi®)

Secukinumab (Cosentyx®)

Tildrakizumab-asmn (IIumya®)

Tocilizumab (Actemra®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®)

Ttislelizumab-jsgr (Tevimbra™)

Vedolizumab (Entyvio®)

Topics due to be included in the Medical Policy Manual on 12/03/2024

Amivantamab-vmjw (Rybrevant™)

Benralizumab (Fasenra®)

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®)

Cerliponase Alfa (Brineura®)

Epcoritamab-bysp (Epkinly™)

Ipilimumab (Yervoy®)

Mepolizumab (Nucala®)

Nivolumab (Opdivo®)

Omalizumab (Xolair®)

Reslizumab (Cinqair®)

Risankizumab-rzaa (Skyrizi®)

Temozolomide (Temodar®), temozolomide

Tezepelumab-ekko (Tezspire®)

Toripalimab-tpzi (Loqtorzi)

Trastuzumab Products (Herceptin®, Ontruzant®, Herzuma®, Ogivri®, Trazimera™, Kanjinti™, Hercessi™)

Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™)

Topics due to be included in the Medical Policy Manual on 12/31/2024:

Daunorubicin and Cytarabine, Liposome (Vyxeos®)

Etranacogene Dezaparvovec-drlb (Hemgenix®)

Goserelin Acetate (Zoladex®)

Leuprolide acetate (Eligard®)

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)

Nelarabine (Arranon®)

Radiofrequency Ablation for Nasal Obstruction and Rhinitis

Testosterone Pellets (Testopel®)

Pharmacy Policies to be Archived on 12/31/2024:

Copanlisib (Aliqopa®) - BCBST plans to archive this pharmcy policy on 12/31/2024.

Moxetumomab pasudotox-tdfk (Lumoxiti®) -  BCBST plans to archive this pharmcy policy on 12/31/2024.

Omacetaxine Mepesuccinate (Synribo®) -  BCBST plans to archive this pharmcy policy on 12/31/2024.

Last Review Date: 10/9/2024