By Karen Blum
To reduce wastage of injectable oncology drugs, oncology societies support the practice of rounding drug doses to the nearest vial size. At AMCP 2024, in New Orleans, representatives from Horizon Blue Cross Blue Shield of New Jersey and Magellan Rx Management shared details from a mandatory program they established to enforce this practice that has nearly tripled prescriber adoption rates and achieved significant cost savings with no detrimental effects on patient care.

The program works as follows: At the time of prior authorization, there is a requirement for vial size optimization driven by a medication’s medical policy. However, there are several instances in which exceptions are made, said Jacob LaRue, PharmD, CPHQ, the assistant vice president of specialty clinical solutions at Magellan: whether a beneficiary is severely ill, whether they have a history of rapidly fluctuating body weight, or whether they had a suboptimal response to a previously rounded dose.

The Hematology/Oncology Pharmacy Association’s position statement on the practice (JCO Oncol Pract 2018;14[3]), endorsed by the National Comprehensive Cancer Network, states that monoclonal antibodies and other biologic pharmaceutical agents can be rounded to the nearest vial size within 10% of the prescribed dose. The statement stresses that dose changes of 10% or less are not expected to reduce drug safety or efficacy. Last November, the American Society of Clinical Oncology released its own clinical guidance on rounding and other strategies in the face of a shortage of 14 oncology drugs (JCO Oncol Pract 2024;20[1]:19-33).

Horizon had implemented a voluntary drug wastage program in June 2018 for its commercial and Medicare plans for 28 drugs tied to the prior authorization process, in which physicians were recommended to optimize vial sizes. They were achieving reasonable results, with about a 30% acceptance rate by providers and a $0.28 per-member per-month savings, said Timothy O’Shea, PharmD, the director of specialty pharmacy for the payor, headquartered in Newark. The top reason for nonacceptance was concern about potential suboptimal outcomes.

However, by transitioning to a mandatory program in May 2022 for its commercial population and increasing the number of drugs to 49, the insurer upped its acceptance rate to 85%, with a $0.95 per-member per-month program savings, Dr. O’Shea said. Clinical exceptions were still permitted, and most commonly related to a beneficiary receiving chemotherapy with a curative intent. Only four clinical denials (<0.5%) were rendered for a refusal to round down without the presence of a clinical exclusion reason.

“You really need the mandatory programs to force the change,” he said.

Getting Buy-In

The presentation was interesting and important in the conversation about how to control medication costs while maintaining the clinical effectiveness of drugs, said Kimberly Lenz, PharmD, MBA, FAMCP, who moderated the session. 

“One of the takeaways I had is how to partner with provider organizations and hospitals so that you get the buy-in for these programs,” said Dr. Lenz, the chief pharmacy officer for MassHealth, Massachusetts’ provider of Medicaid and Children’s Health Insurance Program (CHIP) services. “Otherwise, you’re going to get stuck between providers trying to make sure they’re getting the right dose for their patients while the payor is trying to ensure the appropriate dose while also reducing waste.”

The speakers reported no relevant financial disclosures.