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 10/31/2020

Topics due to be included in the Medical Policy Manual on 12/1/2020

Topics due to be included in the Medical Policy Manual on 12/31/2020

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Topics due to be included in the Medical Policy Manual on 10/31/2020:

Ado-Trastuzumab Emtansine

Atezolizumab

Avelumab

Belantamab mafodotin-blmf

Blinatumomab

Bortezomib (Intravenous Only)

Bortezomib (Velcade)

Brentuximab Vedotin

Cetuximab

Eribulin Mesylate

Fam-trastuzumab Deruxtecan-nxki

Fluocinolone Acetonide Intravitreal Implant for Diabetic Macular Edema (Iluvien)

Obinutuzumab

Paclitaxel (Protein-Bound Particles)

Polatuzumab Vedotin-piiq

Tafasitamab-cxix

Transpupillary Thermotherapy (TTT)

Triptorelin Pamoate

Viltolarsen

Topics due to be included in the Medical Policy Manual on 12/1/2020:

Bendamustine HCl (Bendeka®)

Bendamustine HCl ready-to-dilute (Belrapzo™)

Bendamustine HCl (Treanda®)

Bevacizumab Biosimilar Products for the Treatment of Neoplastic Disease

Bevacizumab for the Treatment of Neoplastic Disease

Canakinumab

Daratumumab

Daunorubicin and Cytarabine Liposome for Injection

Durvalumab

Enfortumab Vedotin-ejfv

Gemtuzumab Ozogamicin

Golimumab for Intravenous Infusion

Home Apnea Monitoring / Home Cardiorespiratory Monitoring

Imiglucerase

Infliximab Biosimilar Products

Infliximab

Ipilimumab

Nivolumab (Intravenous)

Transurethral Waterjet Ablation of the Prostate

Ustekinumab

Zoledronic Acid

Topics due to be included in the Medical Policy Manual on 12/31/2020:

Abatacept (Intravenous)

Atezolizumab

Avelumab

Burosumab-twza

Histrelin Acetate for Central Precocious Puberty (CPP)

Hyaluronan Derivatives for Intra-Articular Injection

Leuprolide Acetate for Depot Suspension

Luspatercept-aamt

Panitumumab

Pembrolizumab

Pemetrexed

Pertuzumab

Ramucirumab

Rituximab Biosimilar Products

Rituximab and Hyaluronidase Human Injection

Rituximab

Romidepsin

Tildrakizumab-asmn

Trabectedin

Trastuzumab Biosimilar Products

Trastuzumab and Hyaluronidase-oysk

Trastuzumab

Triptorelin Extended-Release Injectable Suspension

Effective December 31, 2020: The medical policy for Epidural Steroid Injections for the Treatment of Pain will no longer be utilized by BlueCare.  The MCG guideline for Epidural Steroid Injection (ACG: A-0225) will be utilized for BlueCare Use Only. This MCG Guideline can be viewed on 12/31/2020 using the Cite Guideline Transparency web site: https://bcbst.access.mcg.com/index.


Last Review Date: 10/15/2020

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