CommercialAugust 1, 2021
Specialty dose rounding program for certain oncology medications
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 |
PUBLICATIONS: August 2021 Anthem Provider News - Indiana
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