All Insurance Policy Changes (Page 86)

Continuing from page 85. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Zenocutuzumab-zbco (Bizengri®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is implementing a new prior authorization policy for Zenocutuzumab-zbco (Bizengri®), a targeted cancer therapy for NRG1 gene fusion-positive advanced or metastatic NSCLC, pancreatic adenocarcinoma, and biliary tract cancers. Prior authorization requires documentation of NRG1 gene fusion status and disease progression on prior systemic therapy, with 12-month authorization periods granted for single-agent use. The policy becomes effective September 30, 2026, and must NOT be implemented before that date.
Medium impact
Verteporfin (Visudyne®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Verteporfin (Visudyne®) effective 9/30/2026 that establishes coverage criteria for choroidal neovascularization and choroidal hemangioma treatments. The policy requires step therapy, mandates ophthalmologist prescription, limits treatment spot size to ≤6.4mm diameter, and authorizes 6-month initial coverage with 12-month continuation for demonstrated positive clinical response. This is a future-dated policy not yet implemented.
Medium impact
Triptorelin (Triptodur®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Triptorelin (Triptodur®) covering four indications: central precocious puberty (FDA-approved), gender dysphoria, preservation of ovarian function, and prevention of recurrent menstrual-related attacks in acute porphyria. The policy establishes specific prior authorization requirements, clinical criteria, documentation needs, and prescriber specialty requirements for each indication. This policy is NOT to be implemented until September 30, 2026.
Medium impact
Triamcinolone Acetonide Injectable Suspension (Xipere®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new coverage policy for Xipere® (Triamcinolone Acetonide Injectable Suspension) effective 9/30/2026. The drug is covered for macular edema associated with uveitis when prescribed by an ophthalmologist, requires prior authorization for 12-month periods, and is limited to a maximum dose of 4 mg per eye. All other indications are considered experimental/investigational and not covered.
Medium impact
Tremelimumab-actl (Imjudo®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Tremelimumab-actl (Imjudo®) effective September 30, 2026. The policy covers this immunotherapy drug in combination with durvalumab for four cancer indications: unresectable hepatocellular carcinoma, metastatic NSCLC, and esophageal/gastric adenocarcinomas. Prior authorization will be required with specific genetic testing documentation and treatment combination requirements.
High impact
Tocilizumab (Actemra®); Tocilizumab-anoh (Avtozma®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®), tocilizumab-aazg, tocilizumab-anoh
BCBS Tennessee·Effective Sep 30, 2026
This is a NEW medical policy for Tocilizumab (Actemra and biosimilars) that establishes coverage criteria, prior authorization requirements, and documentation standards for multiple FDA-approved and compendial indications including rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, and others. The policy is NOT effective until 9/30/2026 and should not be implemented before that date.
Medium impact
Tildrakizumab-asmn (IIumya®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is implementing a new prior authorization policy for Tildrakizumab-asmn (Ilumya®), a biologic treatment for moderate to severe plaque psoriasis. Coverage requires specific clinical criteria including prior biologic/targeted synthetic therapy, affected crucial body areas, or significant BSA involvement. The policy becomes effective September 30, 2026, and requires dermatologist prescription with documented TB screening and BSA assessment.
Medium impact
Teprotumumab-trbw (Tepezza®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Teprotumumab-trbw (Tepezza®) for thyroid eye disease treatment, effective 9/30/2026. The policy covers only FDA-approved indications for moderate-to-severe active or inactive TED in patients 18+ years, limited to a single 8-infusion treatment course prescribed by ophthalmologists or endocrinologists. Coverage explicitly excludes repeat treatment series.
High impact
Temozolomide (Temodar®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Temozolomide (Temodar®) establishing coverage criteria for 12+ FDA-approved and compendial oncology indications, including glioblastoma, anaplastic astrocytoma, neuroendocrine tumors, sarcomas, melanomas, and others. The policy requires prior authorization for all covered uses and specifies therapy line requirements and combination therapy rules. This policy is NOT YET EFFECTIVE and must not be implemented until September 30, 2026.
Medium impact
Siltuximab (Sylvant™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Siltuximab (Sylvant™) effective September 30, 2026, establishing coverage criteria for multicentric Castleman's disease, cytokine release syndrome (including CAR T-cell related toxicities), and KSHV-associated inflammatory cytokine syndrome. Prior authorization is required for all indications, with specific eligibility requirements including HIV and HHV-8 status documentation. Authorization periods vary from 1 month (acute CRS) to 12 months (chronic conditions).
High impact
Secukinumab (Cosentyx®)
BCBS Tennessee·Effective Sep 30, 2026
This is a new medical policy for Secukinumab (Cosentyx®) effective 9/30/26 that establishes coverage criteria, prior authorization requirements, and documentation standards for six FDA-approved indications: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, enthesitis-related arthritis, and hidradenitis suppurativa. The policy requires step therapy and mandates prescriber specialty requirements (dermatologist, rheumatologist, or both depending on indication). All other uses are considered experimental/investigational.
Medium impact
Sacituzumab Govitecan-hziy (Trodelvy®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has released a new medical policy for Sacituzumab Govitecan-hziy (Trodelvy®) effective 9/30/2026. The policy establishes coverage criteria for breast cancer and urothelial carcinoma indications, requires prior authorization with specific clinical documentation (HER2, HR, PD-L1 status), and specifies a standardized dosing regimen of 10mg/kg IV on days 1 and 8 of a 21-day cycle. This policy is not yet implemented and should be reviewed well in advance of the effective date.
Medium impact
Ramucirumab (Cyramza®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Ramucirumab (Cyramza®) covering eight cancer indications with specific prior authorization requirements, dosing limits, and continuation criteria. The policy becomes effective September 30, 2026, and requires providers to submit EGFR mutation testing and AFP level results where applicable to obtain prior authorization for treatment.
Medium impact
Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a NEW medical policy for Phesgo™ (Pertuzumab, Trastuzumab and Hyaluronidase-zzxf), a combination biologic for HER2-positive breast cancer treatment. The policy covers three FDA-approved indications (neoadjuvant, adjuvant, and metastatic breast cancer) and allows substitution for IV pertuzumab/trastuzumab combinations. Prior authorization is required with HER2 status documentation, and initial authorization is limited to 12 months.
Medium impact
Pertuzumab (Perjeta®); Pertuzumab-dpzb (Poherdy®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has released a new medical policy for Pertuzumab (Perjeta®) and Pertuzumab-dpzb (Poherdy®) effective September 30, 2026. The policy establishes coverage criteria for pertuzumab across multiple cancer indications including HER2-positive breast cancer (neoadjuvant, adjuvant, and metastatic), colorectal cancer, salivary gland tumors, biliary tract cancers, appendiceal neoplasms, and small bowel adenocarcinoma. All uses require prior authorization with specific genetic marker documentation (HER2, HR, RAS, BRAF status) and must meet defined clinical scenarios.
High impact
Pembrolizumab (Keytruda®)
BCBS Tennessee·Effective Sep 30, 2026
This is a comprehensive new medical policy for Pembrolizumab (Keytruda®) covering FDA-approved indications across multiple cancer types including melanoma, NSCLC, head/neck cancer, lymphomas, urothelial carcinoma, and others. The policy establishes coverage criteria and approved uses but is NOT effective until September 30, 2026, and should NOT be implemented until that date.
Medium impact
Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)
BCBS Tennessee·Effective Sep 30, 2026
This is a new medical policy covering Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) that establishes coverage criteria for multiple cancer indications including melanoma, NSCLC, mesothelioma, head/neck cancers, urothelial cancer, and others. The policy is approved but NOT yet implemented and should not be used until the September 30, 2026 effective date.
High impact
Obinutuzumab (Gazyva®)
BCBS Tennessee·Effective Sep 30, 2026
This is a NEW medical policy (1 day old) for Obinutuzumab (Gazyva®) that establishes coverage criteria, prior authorization requirements, and documentation standards for multiple B-cell lymphomas, chronic lymphocytic leukemia, and lupus nephritis. The policy is APPROVED but NOT YET EFFECTIVE—do not implement until September 30, 2026. Billing teams must prepare systems now to enforce prior authorization requirements and specialty prescriber restrictions when the policy becomes active.
Medium impact
Mogamulizumab-kpkc (Poteligeo®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Mogamulizumab-kpkc (Poteligeo®) covering treatment of relapsed/refractory mycosis fungoides, Sézary syndrome, and adult T-cell leukemia/lymphoma. The policy establishes coverage criteria requiring prior authorization with 12-month authorization periods for covered indications. Policy is not yet effective and should not be implemented until September 30, 2026.
Medium impact
Luspatercept-aamt (Reblozyl®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Luspatercept-aamt (Reblozyl®) effective 9/30/2026, establishing coverage criteria for three indications: beta thalassemia, myelodysplastic syndrome/myeloproliferative neoplasm, and myelofibrosis-associated anemia. Prior authorization is required for all uses, with specific clinical documentation and prescriber specialty requirements. This policy applies to Commercial plans in Tennessee only and includes specific transfusion burden thresholds and hemoglobin level requirements for coverage approval.
Medium impact
Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has established a new medical policy for Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®) effective 9/30/2026, covering two indications: FDA-approved central precocious puberty (CPP) in pediatric patients and compendial use for gender dysphoria in adolescents and adults. The policy requires specific prior authorization criteria, documented laboratory confirmation for CPP, and specialized provider requirements for gender dysphoria cases, including mental health collaboration for members under 18.
Medium impact
Laronidase (Aldurazyme®
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Laronidase (Aldurazyme®) effective 9/30/2026 that establishes coverage criteria for MPS I treatment. The policy requires prior authorization, specific diagnostic confirmation (enzyme assay or genetic testing), and ongoing documentation of clinical response for continuation therapy. This is a foundational coverage policy for a specialized rare disease treatment requiring metabolic disease specialist involvement.
Medium impact
Ixabepilone (Ixempra®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Ixabepilone (Ixempra®) effective 9/30/2026 establishing coverage criteria for breast cancer treatment. The policy covers FDA-approved uses (combination with capecitabine or single agent) and requires prior authorization with HER2 status documentation. This is a NEW policy establishing initial coverage guidelines, not a change to existing policy.
Medium impact
Ipilimumab (Yervoy®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has released a comprehensive medical policy for Ipilimumab (Yervoy®) covering multiple cancer indications with specific prior authorization requirements, documentation standards, and coverage criteria. This policy is not effective until 9/30/2026 and establishes coverage for FDA-approved indications (melanoma, RCC, CRC, HCC, NSCLC, mesothelioma, esophageal cancer) plus compendial uses across numerous other cancer types.
Medium impact
Imetelstat (Rytelo™
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Imetelstat (Rytelo™) effective 9/30/2026, covering treatment of lower-risk myelodysplastic syndromes with transfusion-dependent anemia. The policy requires prior authorization for initial 24-week treatment and 6-month continuation therapy, with specific clinical criteria including failed ESA/luspatercept response and transfusion burden thresholds. Billing teams must prepare authorization workflows and clinical documentation requirements before the effective date.

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Archive by year

2023 2024 2025 2026

Zenocutuzumab-zbco (Bizengri®)

Verteporfin (Visudyne®)

Triptorelin (Triptodur®)

Triamcinolone Acetonide Injectable Suspension (Xipere®)

Tremelimumab-actl (Imjudo®)

Tocilizumab (Actemra®); Tocilizumab-anoh (Avtozma®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®), tocilizumab-aazg, tocilizumab-anoh

Tildrakizumab-asmn (IIumya®)

Teprotumumab-trbw (Tepezza®)

Temozolomide (Temodar®)

Siltuximab (Sylvant™)

Secukinumab (Cosentyx®)

Sacituzumab Govitecan-hziy (Trodelvy®)

Ramucirumab (Cyramza®)

Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)

Pertuzumab (Perjeta®); Pertuzumab-dpzb (Poherdy®)

Pembrolizumab (Keytruda®)

Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)

Obinutuzumab (Gazyva®)

Mogamulizumab-kpkc (Poteligeo®)

Luspatercept-aamt (Reblozyl®)

Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)

Laronidase (Aldurazyme®

Ixabepilone (Ixempra®)

Ipilimumab (Yervoy®)

Imetelstat (Rytelo™