Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued healthcare partner in identifying ways to achieve better health outcomes, lower costs and deliver access to better healthcare experiences for consumers.

 

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

 

 

 

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).

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. IngenioRx, Inc. is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

 

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April 2021 Anthem Provider News - Missouri