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-GA



Featured In:
August 2021 Anthem Provider News - Georgia