Specialty dose rounding program for certain oncology medications

Providers treating members covered by Anthem plans will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications (see list below). Reviews for these oncology drugs will continue to be administered by AIM Specialty Health_® (AIM).

As part of the online prior authorization process, providers will be asked about the dosage of the medication being requested in pop-up questions:

 

• Whether or not the recommended dose reduction is acceptable
• If the patient is considered unable to have his or her dose reduced, then a second question will appear asking for the provider’s clinical reasoning.

 

For prior authorization requests made outside of the online AIM Provider Portal (i.e. via phone or fax) the same questions will be asked by the registered nurse or medical director reviewing the request.  Since this program is voluntary, the decision made regarding dose reduction will not affect the final decision on the prior authorization.

 

The dose reduction questions will appear only if the originally requested dose is within 10 percent of the nearest whole vial. This threshold is based on the current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) it is appropriate to consider dose rounding within 10 percent. Click here to view the HOPA recommendations.

The voluntary dose reduction program only applies to the specific oncology drugs listed below. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Drug Name	HCPCS Code	Drug Name	HCPCS Code
Abraxane (paclitaxel protein-bound)	J9264	Kadcyla (ado-trastuzumab emtansine)	J9354
Actimmune (interferon gamma-1B)	J9216	Kanjinti (trastuzumab-anns)	Q5117
Adcetris (brentuximab vedotin)	J9042	Keytruda (pembrolizumab)	J9271
Alimta (pemetrexed)	J9305	Kyprolis (carfilzomib)	J9047
Asparlas (calaspargase pegol-mknl)	J9118	Lumoxiti (moxetumomab pasudotox-tdfk)	J9313
Avastin (bevacizumab)	J9035	Mvasi (bevacizumab-awwb)	Q5107
Bendeka (bendamustine)	J9034	Mylotarg (gemtuzumab ozogamicin)	J9203
Besponsa (inotuzumab ozogamicin)	J9229	Neupogen (filgrastim)	J1442
Blincyto (blinatumomab)	J9039	Ogivri (trastuzumab-dkst)	Q5114
Cyramza (ramucirumab)	J9308	Oncaspar (pegaspargase)	J9266
Darzalex (daratumumab)	J9145	Ontruzant (trastuzumab-dttb)	Q5112
Doxorubicin liposomal	Q2050	Opdivo (nivolumab)	J9299
Elzonris (tagraxofusp-erzs)	J9269	Padcev (enfortumab vedotin-ejfv)	J9177
Empliciti (elotuzumab)	J9176	Polivy (polatuzumab vedotin-piiq)	J9309
Enhertu (fam-trastuzumab deruxtecan-nxki)	J9358	Riabni (rituximab-arrx)	Q5123
Erbitux (cetuximab)	J9055	Rituxan (rituximab)	J9312
Erwinase (asparginase)	J9019	Ruxience (rituximab-pvvr)	Q5119
Ethyol (amifostine)	J0207	Sarclisa (isatuximab-irfc)	J9227
Granix (tbo-filgrastim)	J1447	Sylvant (siltuximab)	J2860
Halaven (eribulin mesylate)	J9179	Trazimera (trastuzumab-qyyp)	Q5116
Herceptin (trastuzumab)	J9355	Treanda (bendamustine)	J9033
Herzuma (trastuzumab-pkrb)	Q5113	Truxima (rituximab-abbs)	Q5115
Imfinzi (durvalumab)	J9173	Vectibix (panitumumab)	J9303
Istodax (romidepsin)	J9315	Yervoy (ipilimumab)	J9228
Ixempra (ixabepilone)	J9207	Zaltrap (ziv-aflibercept)	J9400
Jevtana (cabazitaxel)	J9043	Zirabev (bevacizumab-bvzr)	Q5118

Note: In some plans “dose reduction to nearest whole vial” or another term “waste reduction” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “dose reduction to nearest whole vial” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “dose reduction (to nearest whole vial).”

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

1245-0821-PN-CA