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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 10/31/2026
Topics
due to be included in the Medical Policy Manual on 11/01/2026
Topics
due to be included in the Medical Policy Manual on 12/01/2026
Topics due to be included in
the Medical Policy Manual on 10/31/2026
Biofeedback and Neurofeedback
Canakinumab (Ilaris®)
Daratumumab (Darzalex®)
Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)
Denosumab Products: Denosumab (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-desu (Osvyrti); Denosumab-adet (Ponlimsi™); Denosumab-bmwo (Stoboclo®)
Denosumab Products: Denosumab (Xgeva®); Denosumab-kyqq (Aukelso™); Denosumab-nxxp (Bilprevda®); Denosumab-bnht (Bomyntra®); Denosumab-desu (Jubereq); Denosumab-bmwo (Osenvelt®); Denosumab-mobz (Oziltus®); Denosumab-bbdz (Wyost®); Denosumab-dssb (Xbryk™), Denosumab-qbde (Xtrenbo™)
Durvalumab (Imfinzi®)
Elosulfase Alfa (Vimizim®)
Eptinezumab-jjmr (Vyepti®)
Eteplirsen (Exondys 51™)
Imiglucerase (Cerezyme®)
Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra); infliximab; infliximababda
Intravenous Immune Globulin (IVIG)
Leuprolide Acetate (Fensolvi®)
Nivolumab (Opdivo®)
Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)
Pegfilgrastim (Neulasta®); Pegfilgrastim-unne ( Armlupeg® ); Pegfilgrastim-pccg (Ennumo™); Pegfilgrastim-jmdb (Fulphila®); Pegfilgrastim-pbbk (Fylnetra®); Pegfilgrastim-apgf (Nyvepria™); Pegfilgrastim-fpgk (Stimufend®); Pegfilgrastim-cbqv (Udenyca®); Pegfilgrastim-bmez (Ziextenzo™)
Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)
Pembrolizumab (Keytruda®)
Ranibizumab (Lucentis®); Ranibizumab-nuna [Byooviz™]; Ranibizumab-eqrn [Cimerli™]; Ranibizumab-leyk [Nufymco™]; Ranibizumab-hkdz [Ranluspec®]
Taliglucerase Alfa (Elelyso®)
Teprotumumab-trbw (Tepezza®)
Velaglucerase Alfa (VPRIV®)
Vestronidase Alfa-vjbk (Mepsevii®)
Topics due to be included in
the Medical Policy Manual on 11/01/2026
Commercial & BlueCare PASD Step Therapy Requirements
Topics due to be included in
the Medical Policy Manual on 12/01/2026
Aflibercept Products (Eylea®; Eylea®HD, Ahzantive™ [aflibercept-mrbb], Enzeevu™ [Aflibercept-abzv], Eydenzelt® [Aflibercept-boav], Opuviz™ [Aflibercept-yszy], Pavblu™ [Aflibercept-ayyh], and Yesafili™ [Aflibercept-jbvf])
Agalsidase Beta (Fabrazyme®)
Alglucosidase Alfa (Lumizyme®)
Amivantamab-vmjw (Rybrevant™)
Amivantamab and Hyaluronidase-lpuj (Rybrevant Faspro™)
Atidarsagene Autotemcel (LENMELDY™)
Avalglucosidase Alfa-ngpt (Nexviazyme™)
Benralizumab (Fasenra®)
Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)
Brolucizumab-dbll (Beovu®)
Depemokimab-ulaa (Exdensur)
Faricimab-svoa (Vabysmo™)
Goserelin Acetate (Zoladex®)
Guselkumab (Tremfya ®)
Histrelin Acetate (Supprelin® LA)
Ipilimumab (Yervoy®)
Leuprolide acetate (Eligard®, Vabrinty™)
Leuprolide Acetate (Fensolvi®)
Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg)
Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)
Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)
Leuprolide Mesylate (Camcevi ETM™; Camcevi Kit)
Mepolizumab (Nucala®)
Mirikizumab-mrkz (Omvoh)
Nivolumab (Opdivo®)
Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)
Nusinersen (Spinraza™)
Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)
Pasireotide (Signifor® LAR)
Pegunigalsidase Alfa-iwxj (Elfabrio®)
Ranibizumab (Susvimo®)
Reslizumab (Cinqair®)
Risankizumab-rzaa (Skyrizi®)
Sebelipase Alfa (Kanuma®)
Tarlatamab-dlle (Imdelltra™)
Telisotuzumab vedotin-tllv (Emrelis™)
Testosterone Product: (Testosterone Pellets [Testopel®])
Tezepelumab-ekko (Tezspire®)
Toripalimab-tpzi (Loqtorzi)
Triptorelin (Triptodur®)
Triptorelin Pamoate (Trelstar®)
Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza)
Vedolizumab (Entyvio®)
Last Review Date: 9/30/2026
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.
Pharmacy Policy Comments:
Please reference the policy name in your comments.
To submit comments about the upcoming Pharmacy policies:
Click the “Pharmacy 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