I. Dose rounding for infused drug products to the nearest lowest vial size if within +/- 10% of the original prescribed dose («the Recommended Dose») will be required unless the following medical necessity criteria are met:
a. Provider indicates Recommended Dose may result in a suboptimal outcome due to one of the following:
i. Member’s age is less than 18 years of age
ii. Member previously demonstrated a suboptimal response to a lower rounded down dose
iii. Member is clinically unstable and at high risk for hospitalization if the requested medication produces a suboptimal response
iv. Member’s laboratory values indicate that a dose reduction resulted in a suboptimal response
v. Patients with relevant enzyme deficiencies, or genetic polymorphisms may not be good candidates for dose rounding
b. All other reasons not mentioned in this policy are not considered medically necessary.
