Specialty dose rounding program for certain oncology medications

Providers treating members covered by Anthem Blue Cross and Blue Shield (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.

 

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.

 

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

 

1245-0821-PN-CNT