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 4/2/2019

Topics due to be included in the Medical Policy Manual on 4/30/2019

Topics due to be included in the Medical Policy Manual on 5/31/2019

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Topics due to be included in the Medical Policy Manual on 4/2/2019:

Abatacept

AbobotulinumtoxinA

Aflibercept

C1 Esterase Inhibitor (Cinryze®)

C1 Esterase Inhibitor (Ruconest®)

C1 Esterase Inhibitor (Berinert®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda)

Collagenase Clostridium Histolyticum

Copanlisib

Galsulfase

Gemtuzumab Ozogamicin

Gender Reassignment Surgery

Granisetron Extended-Release Injection

Icatibant

IncobotulinumtoxinA

Infliximab-abda

Infliximab-dyyb

Levoleucovorin (Khapzory)

Ocrelizumab

Olaratumab

OnabotulinumtoxinA

Pegfilgrastim-cbqv

RimabotulinumtoxinB

Tildrakizumab

Tisagenlecleucel

Tocilizumab

Medical Policies to be Archived:

Capecitabine - This medical policy document will be archived (i.e., no longer used) by BCBST as of April 2, 2019.

Topics due to be included in the Medical Policy Manual on 4/30/2019:

Applied Behavioral Analysis (ABA)

Aqueous Shunts and Stents for Glaucoma

Azacitidine

Browplasty

Emapalumab-lzsg

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Oscillating Devices for the Treatment of Respiratory Conditions

Pneumatic Compression Pumps

Rituximab-abbs

Trastuzumab-pkrb

Trastuzumab

Radiotherapy for Prostate Cancer - BCBST will no longer address brachytherapy for prostate cancer within this medical policy document. That portion of this medical policy will be deleted. Going forward we will utilize the MCG Guideline A-0270 addressing this subject.

Topics due to be included in the Medical Policy Manual on 5/31/2019:

Ado-Trastuzumab Emtansine

Aldesleukin

Alemtuzumab

Asparaginase Erwinia chrysanthemi

Atezolizumab

Belinostat

Bevacizumab for the Treatment of Neoplastic Disease

Calaspargase Pegol-mknl

Cetuximab

Elotuzumab

Inotersen

Ipilimumab

Omacetaxine

Panitumumab

Patisiran

Pegaspargase

Pembrolizumab

Pemetrexed

Pralatrexate

Ramucirumab

Ravulizumab-cwvz

Rituximab

Rituximab-abbs

Romiplostim

Tagraxofusp-erzs

Trastuzumab

Trastuzumab-dttb

Ziv-Aflibercept

 


Last Review Date: 3/2/2019

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