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 08/30/2025

Topics due to be included in the Medical Policy Manual on 09/30/2025

Topics due to be included in the Medical Policy Manual on 08/30/2025

Daratumumab (Darzalex®)

Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)

Etranacogene Dezaparvovec-drlb (Hemgenix®)

Inclisiran (Leqvio®)

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), infliximab

Isatuximab-irfc (Sarclisa®)

Nedosiran (Rivfloza™)

Negative Pressure Wound Therapy in the Outpatient Setting

Nivolumab/Relatlimab-rmbw (Opdualag™)

Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension

Pharmacogenetic Testing for Pain Management

Risankizumab-rzaa (Skyrizi®)

Talimogene Laherparepvec (Imlygic™)

Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab- (UsIrmslftu elkdionsuam™ab); (USstetelakrian®u)m; Uasbt-eakaiunzu m(Oatbu-lfaiu™u)b; U(Wsteeznlakninau™m); aUbs-tetwkien (uPmyazcbh-sivrlaf ™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumabaekn;
ustenkinumab-ttwe

Topics due to be included in the Medical Policy Manual on 09/30/2025

Abraxane® (paclitaxel, albumin-bound) paclitaxel, albumin-bound

Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin-C®, Zemaira®)

Anifrolumab-fnia (Saphnelo®)

Azacitidine (Vidaza®)

Belimumab (Benlysta®)

Beremagene Geperpavec-svdt (Vyjuvek™)

Canakinumab (Ilaris®)

Cipaglucosidase Alfa-atga (Pombiliti™)

Circulating Tumor DNA (Liquid Biopsy)

Complementary and Alternative Medicine

Durvalumab (Imfinzi®)

Elosulfase Alfa (Vimizim®)

Galsulfase (Naglazyme®)

Idursulfase (Elaprase®)

Imetelstat (Rytelo™)

Imiglucerase (Cerezyme®)

Laronidase (Aldurazyme®)

Pegcetacoplan (Syfovre™)

Pertuzumab (Perjeta®)

Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)

Romidepsin [Istodax®; Romidepsin (liquid)]

Sacituzumab Govitecan-hziy (Trodelvy®

Secukinumab (Cosentyx®)

Siltuximab (Sylvant™)

Taliglucerase Alfa (Elelyso®)

Temozolomide (Temodar®), temozolomide

Tildrakizumab-asmn (IIumya®)

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

Tremelimumab-actl (Imjudo®)

Velaglucerase Alfa (VPRIV®)

Vestronidase Alfa-vjbk (Mepsevii®)

Voretigene Neparvovec-rzyl (Luxturna®)

Medical policies to be Archived on 09/30/2025:

 Remdesivir (Veklury®) as an Outpatient Treatment of COVID-19 - Pharmacy plans to archive due to decreased utilization and broader clinical experience.

Last Review Date: 7/31/2025