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 07/01/2025

Topics due to be included in the Medical Policy Manual on 07/31/2025

Topics due to be included in the Medical Policy Manual on 08/30/2025

Topics due to be included in the Medical Policy Manual on 07/01/2025

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

Brentuximab Vedotin (Adcetris®)

C1 Esterase Inhibitor (Human) Cinryze®

C1 Esterase Inhibitor (recombinant) (Ruconest®)

C1 Esterase Inhibitor Subcutaneous (Human) Haegarda®

C1 Esterase Inhibitor (Human) (Berinert®)

Ecallantide (Kalbitor®)

Eculizumab Products (Soliris®, Bkemv™ [Eculizumab-aeeb], and Epysqli® [Eculizumab-aagh])

Efgartigimod Alfa-fcab (Vyvgart®); Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo)

Fam-trastuzumab Deruxtecan-nxki (Enhertu®)

Home Nutritional Support (Total Parenteral / Enteral Nutrition)

Icatibant (Firazyr®), Icatibant (Sajazir™), Icatibant

Irinotecan Liposome Injection (Onivyde®)

Lanadelumab-flyo (Takhzyro®)

Mosunetuzumab-axgb (Lunsumio™)

Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU, Axtle™

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

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

Sacituzumab Govitecan-hziy (Trodelvy®)

Secukinumab (Cosentyx®)

Trabectedin (Yondelis®)

Ublituximab-xiiy (Briumvi™)

Topics due to be included in the Medical Policy Manual on 07/31/2025

Avacincaptad Pegol (Izervay™)

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®)

Carfilzomib (Kyprolis®)

Cemiplimab-rwlc (Libtayo®)

Certolizumab Pegol (Cimzia®)

Denosumab Products: (Prolia®); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-bmwo (Stoboclo®); Denosumab-bnht (Conexxence®)

Elivaldogene Autotemcel (Skysona®)

Evinacumab-dgnb (Evkeeza™)

Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies

Fidanacogene Elaparvovec-dzkt (BEQVEZ ™)

Fluocinolone Acetonide Implant (Iluvien®)

Fosdenopterin (Nulibry™)

Guselkumab (Tremfya®)

Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto®)

Mirikizumab-mrkz (Omvoh)

Nusinersen (Spinraza™)

Olipudase Alfa-rpcp (Xenpozyme™)

Retifanlimab-dlwr (Zynyz™)

Spesolimab-sbzo (Spevigo®)

Tislelizumab-jsgr (TEVIMBRA™)

Valoctocogene Roxaparvovec-rvox (Roctavian®)

Vedolizumab (Entyvio®)

Velmanase Alfa-tycv (Lamzede®)

Zoledronic Acid (Reclast®)

Zoledronic Acid (Zometa®), Zoledronic Acid

Topics due to be included in the Medical Policy Manual on 08/30/2025

Daratumumab (Darzalex®)

Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)

Etranacogene Dezaparvovec-drlb (Hemgenix®)

Inclisiran (Leqvio®)

Infliximab Products: Infliximab (Remicade®); Infliximab axxq (Avsola™); Infliximab dyyb (Inflectra™); Infliximab abda (Renflexis™); Infliximab-dyyb (Zymfentra), infliximab

Isatuximab-irfc (Sarclisa®)

Nedosiran (Rivfloza™)

Negative Pressure Wound Therapy in the Outpatient Setting

Nivolumab/Relatlimab-rmbw (Opdualag™)

Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension

Pharmacogenetic Testing for Pain Management

Risankizumab-rzaa (Skyrizi®)

Talimogene Laherparepvec (Imlygic™)

Ustekinumab Product (UImstuelkdionsuam™ab); (USstetelakrian®u)m; Uasbt-eakaiunzu m(Oatbu-lfaiu™u)b; U(Wsteeznlakninau™m); aUbs-tetwkien (uPmyazcbh-sivrlaf ™), Ustekinumab-aekn
(Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumabaekn;
ustenkinumab-ttwe

Last Review Date: 6/12/2025