Managing Bispecifics at Scale: Capacity Planning, Financial Clearance, and Monitoring

Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA, the director of pharmacy – Advanced therapeutics at Kansas Cancer Center in Kansas City, explains how pharmacy leadership is central to safely and efficiently delivering bispecific therapies across oncology. They break down the multiple “swim lanes” involved—patient selection, prior authorization, financial mitigation, toxicity monitoring, and capacity planning—and describe how pharmacy helps standardize workflows while still accounting for product- and patient-specific differences.

Pharmacy Times: How can pharmacy leadership design standardized pathways for bispecific antibodies that balance infusion center capacity with appropriate monitoring requirements?

Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA: That's kind of the day-to-day challenge—understanding our pharmacy leadership and separating that pathway from the individual components. There are so many different swim lanes happening all at the same time. You have a patient selection swim lane, authorization and financial mitigation swim lanes, and then monitoring, toxicity, and treatment interruptions. All of those converge at the same point.

Not every dose requires the same level of resources. With step-up doses and the first full dose, those may require longer appointments, additional assessments, and likely more intensive monitoring, while later doses can be managed far more streamlined once the patient has demonstrated tolerability. Building and anticipating those differences into the scheduling templates prevents every visit from being treated as though it carries the same risk — because it doesn't.

Pharmacy is exceptional at creating order sets with a common institutional framework: standardized elements including laboratory parameters, pre-medications, hydration when appropriate, assessments for CRS and neurotoxicity, supportive care requirements, and guidance on when to hold a dose if the patient requires a hold. Those are all areas where pharmacy can contribute meaningfully.

Pharmacy also contributes to capacity planning, which should include designated administration days, limits on the number of new starts, coordination between inpatient and outpatient settings, and confirmation that rescue medications like tocilizumab are immediately available. The objective is not to force every bispecific into an identical workflow but to create a reliable one—standardizing decision-making processes while preserving product-specific and patient-specific differences. Bispecifics are not limited to multiple myeloma; we have them in lung cancer and in lymphoma, and we anticipate rapid growth in this space.

Pharmacy Times: How can pharmacy teams work with revenue cycle and billing departments to accurately capture reimbursement for complex immunotherapy pathways?

Mahmoudjafari: This is becoming increasingly commonplace.

The most important step is simply bringing together two groups that have previously worked independently into regular meetings at a predictable frequency. They need to understand the revenue cycle and billing before treatment begins — nothing is more complicated than addressing those questions once a patient is actively in treatment.

Pharmacy can provide a detailed map of the complete treatment episode, including the product, dose escalation schedule, route of administration, monitoring periods, and all the elements that comprise that episode of care, as well as the circumstances that can lead to an observation status or inpatient admission. From there, it's about connecting that information to the correct drug code, administration code, site-of-care designation, diagnosis documentation, and payer authorization.

Pharmacy also becomes deeply involved in drug purchasing, inventory, administration, and waste documentation to reconcile with the claim. Pharmacy tends to be present at every juncture. We want to ensure financial clearance checkpoints before every new start—confirming authorization for that exact product, that dose, that schedule, and that intended site of care, not simply a general authorization.

After that, teams should participate in the auditing process to confirm that initial claims are performing as anticipated and that reimbursement is coming in as expected. If it isn't, where were the gaps, and where can we course-correct?

I'll admit I'm biased when I say pharmacy often serves as that bridge—but it's because we understand both the financial elements and the clinical regimen at the product-level detail required for accurate billing. The goal is to create a closed-loop process where clinical decisions generate the correct documentation and charges and where reimbursement outcomes are reviewed routinely rather than discovered months later.