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 01/30/2021

Topics due to be included in the Medical Policy Manual on 03/02/2021

Topics due to be included in the Medical Policy Manual on 04/02/2021

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Topics due to be included in the Medical Policy Manual on 01/30/2021:

Ado-Trastuzumab Emtansine

Balloon Dilation of the Eustachian Tube

Belinostat

Bendamustine HCl ready-to-dilute (Belrapzo™)

Bendamustine HCl (Bendeka®)

Bendamustine HCl (Treanda®)

Bevacizumab Biosimilar Products for the Treatment of Neoplastic Disease

Bevacizumab for the Treatment of Neoplastic Disease

Bortezomib (Intravenous Only)

Bortezomib (Velcade®)

Brentuximab Vedotin

Certolizumab Pegol

Cetuximab

Circulating Tumor DNA Multi-Panel Testing and Circulating Tumor Cells (Liquid Biopsy)

Fam-Trastuzumab Deruxtecan-nxki

Mogamulizumab-kpkc

Obinutuzumab

Paclitaxel (Protein-Bound Particles)

To be archived on 1/30/2021:

Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation - This medical policy will be archived and BCBST will transition over to the MCG guideline for Left Atrial Appendage Closure, Percutaneous (M-333). This MCG Guideline may be viewed on 1/30/2021 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.

Zoster Vaccine (Live) - As of July 2020 Zostavax is no longer marketed in the United States; therefore, there this medical policy is no longer of value to retain.

Topics due to be included in the Medical Policy Manual on 03/02/2021:

Alemtuzumab

Breast Cancer Gene Expression Assays

Icatibant

Intravenous Immune Globulin (IVIG) Therapy

Mepolizumab

Moxetumomab pasudotox-tdfk

Natalizumab

Ocrelizumab

Omalizumab

Pegloticase

Reslizumab

Rituximab Biosimilar Products

Rituximab and Hyaluronidase Human Injection

Rituximab

Subcutaneous Immune Globulins

Testosterone Pellets for Subcutaneous Implantation

Tocilizumab (Intravenous)

Ustekinumab

Vedolizumab

To be archived on 3/2/2021:

Molecular Anatomic Pathology Testing - This medical policy will be archived on March 2, 2021. BCBST will be transitioning over to using an available MCG guideline to address this test.  The BCBST medical policy and MCG guideline deem this test to be investigational. 

Ocriplasmin - As of May 2020 this product is no longer manufactured and marketed in the USA.

Pegademase Bovine - As of July 2019 this product has been discontinued and is no longer marketed in the USA.

Topics due to be included in the Medical Policy Manual on 04/02/2021:

Aflibercept

Axicabtagene Ciloleucel

Bendamustine HCl (Treanda®)

C1 Esterase Inhibitor (Human) (Cinryze®)

C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)

C1 Esterase Inhibitor (Human) (Berinert®)

C1 Esterase Inhibitor (recombinant) (Ruconest®)

Copanlisib

Daratumumab

Ecallantide

Eculizumab

Gemcitabine in Sodium Chloride Injection

Gemtuzumab Ozogamicin

Golimumab for Intravenous Infusion

Golodirsen

Hyaluronan Derivatives for Intra-Articular Injection

Inotuzumab Ozogamicin

Ipilimumab

Lanadelumab-flyo

Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids

Nivolumab (Intravenous)

Pegaptanib Sodium

Pegaspargase

Ranibizumab

Transcranial Magnetic Stimulation (TMS)

Tafasitamab-cxix

Temozolomide for Injection

Tisagenlecleucel

Tocilizumab (Intravenous)

Verteporfin

Vincristine Sulfate Liposome Injection


Last Review Date: 1/14/2021

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