Medicare AdvantageApril 1, 2021
Oncology dose reduction program beginning July 1, 2021
Effective for dates of service on or after July 1, 2021, providers for our Medicare Advantage plan members covered by Anthem will be asked in selective circumstances to voluntarily reduce the requested dose to the nearest whole vial for over 40 oncology medications, listed below. Reviews for these oncology drugs will continue to be administered by the reviewing company, either AIM Specialty Health®* or IngenioRx.*
Providers will be asked whether or not they will accept the dose reduction at the initial review point in the prior authorization process. Within the provider portal, a pop-up question will appear related to dose reduction. 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 requests made outside of the provider portal (for example, called-in or faxed-in prior authorization requests), the same questions will be asked by the registered nurse or medical director who is 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% of the nearest whole vial. This threshold is based on current medical literature and recommendations from the Hematology and Oncology Pharmacists Association (HOPA) that it is appropriate to consider dose rounding within 10%. HOPA recommendations can be found here.
The voluntary dose reduction program only applies to specific oncology drugs, listed below. Providers can view prior authorization requirements for Anthem members on the medical policy and clinical utilization management guidelines page at anthem.com/medicareprovider.
Drug name |
HCPCS code |
Drug name |
HCPCS code |
Abraxane (paclitaxel protein-bound) |
J9264 |
Istodax (romidepsin) |
J9315 |
Actimmune (interferon gamma-1B) |
J9216 |
Ixempra (ixabepilone) |
J9207 |
Adcetris (brentuximab vedotin) |
J9042 |
Jevtana (cabazitaxel) |
J9043 |
Alimta (pemetrexed) |
J9305 |
Kadcyla (ado-trastuzumab emtansine) |
J9354 |
Asparlas (calaspargase pegol-mknl) |
J9118 |
Keytruda (pembrolizumab) |
J9271 |
Avastin (bevacizumab) |
J9035 |
Kyprolis (carfilzomib) |
J9047 |
Bendeka (bendamustine) |
J9034 |
Lartruvo (olaratumab) |
J9285 |
Besponsa (inotuzumab ozogamicin) |
J9229 |
Lumoxiti (moxetumomab pasudotox-tdfk) |
J9313 |
Blincyto (blinatumomab) |
J9039 |
Mylotarg (gemtuzumab ozogamicin) |
J9203 |
Cyramza (ramucirumab) |
J9308 |
Neupogen (filgrastim) |
J1442 |
Darzalex (daratumumab) |
J9145 |
Oncaspar (pegaspargase) |
J9266 |
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 |
Rituxan (rituximab) |
J9312 |
Erbitux (cetuximab) |
J9055 |
Sarclisa (isatuximab-irfc) |
J9999 |
Erwinase (asparginase) |
J9019 |
Sylvant (siltuximab) |
J2860 |
Ethyol (amifostine) |
J0207 |
Treanda (bendamustine) |
J9033 |
Granix (tbo-filgrastim) |
J1447 |
Vectibix (panitumumab) |
J9303 |
Halaven (eribulin mesylate) |
J9179 |
Yervoy (ipilimumab) |
J9228 |
Herceptin (trastuzumab) |
J9355 |
Zaltrap (ziv-aflibercept) |
J9400 |
Imfinzi (durvalumab) |
J9173 |
|
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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.
Note: In some plans, dose reduction to nearest whole vial or 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. In some plans, these terms may be used interchangeably. For simplicity, we have uses dose reduction (to nearest whole vial).
PUBLICATIONS: April 2021 Anthem Provider News - Georgia
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