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 07/31/2021

Topics due to be included in the Medical Policy Manual on 08/31/2021

Topics due to be included in the Medical Policy Manual on 09/30/2021

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Topics due to be included in the Medical Policy Manual on 07/31/2021:

Ado-Trastuzumab (Kadcyla®)

Atezolizumab (Tecentriq®)

Avelumab (Bavencio®)

Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Rhinosinusitis

Belinostat (Beleodaq®)

Bendamustine Products (Treanda®, Belrapzo®, Bendeka®)

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

Brentuximab Vedotin (Adcetris®)

Cetuximab (Erbitux®)

Daratumumab (Darzalex®)

Durvalumab (Imfinzi®)

Dostarlimab-gxly (Jemperli®)

Elotuzumab (Empliciti®)

Ipilimumab (Yervoy®)

Loncastuximab Tesirine-lpyl (Zynlonta™)

Mepolizumab (Nucala®)

Microwave Ablation for Oncologic Tumors

Obinutuzumab (Gazyva®)

Paclitaxel (Protein-Bound Particles) (Abraxane®)

Panitumumab (Vectibix®)

Pemetrexed (Alimta®)

Pertuzumab (Perjeta®)

Ramucirumab (Cyramza®)

Rituximab and Hyaluronidase Human Injection (Rituxan Hycela®)

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

Trabectedin (Yondelis®)

Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta™)

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

Medical Policies to be Archived on 7/31/2021:

Genetic Testing for Cutaneous Malignant Melanoma - BCBST will be archiving this medical policy effective July 31, 2021 and transition over to the MCG Care Guideline titled Malignant Melanoma (Cutaneous) (ACG: A-0601). The MCG Care Guideline position aligns with the current BCBST medical policy and may be viewed using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Proteogenomic Testing for Individuals with Cancer - BCBST will be archiving this medical policy effective July 31, 2021.

Topics due to be included in the Medical Policy Manual on 08/31/2021:

AbobotulinumtoxinA (Dysport®)

Agalsidase Beta (Fabrazyme®)

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

Atezolizumab (Tecentriq®)

Axicabtagene Ciloleucel (Yescarta®)

Azacitidine (Vidaza®)

Belimumab (Benlysta®)

Burosumab-twza (Crysvita®)

Cabazitaxel (Jevtana®)

Coronary Computed Tomography Angiography (CCTA)

Corticotropin Therapy (HP Acthar®)

Darbepoetin Alfa for Dialysis (Aranesp®)

Darbepoetin Alfa for Non-Dialysis (Aranesp®)

Daunorubicin and Cytarabine, Liposome (Vyxeos®)

Denosumab (Prolia®, Xgeva®)

Epoetin Alfa Products for Dialysis (Epogen®, Procrit®, Retacrit®)

Epoetin Alfa Products for Non-Dialysis (Epogen®, Procrit®, Retacrit®)

Eptinezumab-jjmr (Vyepti®)

Gemcitabine in Sodium Chloride Injection (Infugem®)

IncobotulinumtoxinA (Xeomin®)

Irinotecan Liposome Injection (Onivyde®)

Ixabepilone (Ixempra®)

Leuprolide Acetate for Depot Suspension (Lupron Depot®, Lupron Depot-Ped®, Eligard®, Fensolvi®)

Luspatercept-aamt (Reblozyl®)

Methoxy Polyethylene Glycol-Epoetin Beta for Dialysis (Mircera®)

Methoxy Polyethylene Glycol-Epoetin Beta for Non-Dialysis (Mircera®)

Mitomycin Gel (Jelmyto®)

Necitumumab (Portrazza®)

Nivolumab (Opdivo®) (Intravenous)

Octreotide Acetate Long-Acting Dosage Form (Sandostatin® LAR)

Ofatumumab (Arzerra®)

OnabotulinumtoxinA (Botox®)

Pegfilgrastim Products (Neulasta®; Fulphila™; Udenyca®; Ziextenzo™; Nyvepria™)

Pembrolizumab (Keytruda®)

Positron Emission Tomography (PET) for Miscellaneous Applications

RimabotulinumtoxinB (Myobloc®)

Romosozumab-AQQG (Evenity®)

Sargramostim (Leukine®)

Sipuleucel-T (Provenge®)

Tagraxofusp-erzs (Elzonris®)

Talimogene Laherparepvec (Imlygic®)

Temsirolimus (Torisel®)

Triptorelin Pamoate (Trelstar®)

Whole Exome and Genome Sequencing

Zoledronic Acid (Zometa®, Reclast®)

Topics due to be included in the Medical Policy Manual on 09/30/2021:

Avelumab (Bavencio®)

Carfilzomib (Kyprolis®)

Cemiplimab-rwlc (Libtayo®)

Daratumumab (Darzalex®)

First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment

Omalizumab (Xolair®)

Paclitaxel (Protein-Bound Particles) (Abraxane®)

Ramucirumab (Cyramza®)


Last Review Date: 7/13/2021

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