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BCBS Horizon

BCBS Horizon Medical Policy Updates – May 2019

Click here to view the Blue Cross Blue Shield Horizon Medical Policy Updates »

May 2019 Medical Policy Updates:

  • Alkylating Agent(s) [Temozolomide intravenous (Temodar)]
  • Ambulance and Medical Transport Services or Ancillary Ambulance Items and Supplies
  • Atezolizumab (Tecentriq)
  • Avelumab (Bavencio)
  • Belimumab (Benlysta)
  • Belinostat (Beleodaq)
  • Blepharoplasty
  • Botulinum Toxin
  • Breast Pumps
  • Brentuximab Vedotin (Adcetris)
  • Canakinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Cerliponase Alfa (Brineura)
  • Certolizumab Pegol (Cimzia)
  • Compression Stockings
  • Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
  • Cosmetic Procedures
  • Cutaneous Electrogastrography (EGG)
  • Daratumumab (Darzalex)
  • Dermatologic Applications of Photodynamic Therapy
  • Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
  • Drug Testing in Pain Management and Substance Use Disorder Treatment Settings
  • Dry Needling of Myofascial Trigger Points
  • Dupilumab (Dupixent)
  • Dynamic Splinting Devices
  • Edaravone (Radicava)
  • Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems)
  • Erythropoietin Therapy Epoetin Alfa Darbepoetin Alfa Pegylated (PEG)-epoetin Beta and Epoetin Alfa-epbx
  • Explantation of Breast Implants
  • Fulvestrant (Faslodex)
  • Gazyva (Obinutuzumab)
  • Gender Reassignment Surgery
  • Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon)]
  • Gonadotropin-Releasing Hormone Analogs
  • Hyperbaric Oxygen Therapy
  • Imlygic (Talimogene Laherparepvec)
  • Inotuzumab Ozogamicin (Besponsa)
  • Insulin Infusion Pumps
  • Intravenous Immunoglobulin (IVIG) Therapy
  • Lemtrada (Alemtuzumab)
  • Marqibo (Vincristine Sulfate Liposome Injection)
  • Medical Beds
  • Molecular Analysis for Targeted Therapy for Non-Small-Cell Lung Cancer
  • Monoclonal Interleukin-5 Antagonists [mepolizumab (Nucala) reslizumab (Cinqair) and benralizumab (Fasenra)]
  • Mozobil (Plerixafor Injection)
  • Ocrelizumab (Ocrevus)
  • Ofatumumab (Arzerra)
  • Omacetaxine Mepesuccinate (Synribo)
  • Omalizumab (Xolair)
  • Oxaliplatin (Eloxatin)
  • Pediatric Intensive Feeding Programs
  • Pralatrexate (Folotyn)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Sipuleucel-T (Provenge)
  • Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
  • Testosterone [Implantable Testosterone Pellets (Testopel Pellets) Testosterone Undecanoate (Aveed)] Testosterone Cypionate (Depo-Testosterone) or Testosterone Enanthate (Delatestryl)]
  • Tildrakizumab (Ilumya)
  • Tocilizumab (Actemra)
  • Topotecan Hydrochloride (Hycamtin) Injection
  • Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization
  • Tumor Markers Other Than Prostate Specific Antigen (PSA)
  • Ustekinumab (Stelara)
  • Voretigene neparvovec-rzyl (Luxturna)
  • Whole-Body CT Screening


Click here to view the Blue Cross Blue Shield Horizon Medical Policy Updates »


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