Centene NK1 antagonist Coverage & Prior Auth Update

Coverage Criteria

Initial Therapy — CINV

Initial approval for prevention of chemotherapy‑induced nausea and vomiting: Covered when ALL of the following are met

Core criteria: 1) Request is for generic aprepitant capsules, Emend, Cinvanti, or Focinvez; 2) Prescribed for prevention of chemotherapy‑induced nausea/vomiting; 3) Patient age meets formulation‑specific minimums (e.g., Emend oral suspension/Emend for injection/Focinvez: >=6 months; Emend capsules: >=12 years; Cinvanti: >=18 years); 4) Patient is scheduled to receive moderately to highly emetogenic cancer chemotherapy (see Appendix D); 5) Prescribed in combination with a serotonin (5‑HT3) receptor antagonist (ondansetron preferred) and dexamethasone; 6) Member must use generic aprepitant or fosaprepitant unless contraindicated or clinically significant adverse effects are experienced; 7) If request is for brand Emend, Focinvez, or Cinvanti, one of the following must apply: a) clinical contraindication/intolerance to generic, or b) request is for treatment associated with cancer in a state with regulations against step therapy in certain oncology settings (see Appendix E).

Dosing limits and single‑dose vs 3‑day regimens specified by age and formulation in policy (see dosing sections).

Continuation Therapy — CINV

Continued therapy (re‑authorization) for CINV: Covered when ALL of the following are met

Continuation criteria: 1) Member is currently receiving medication via Centene benefit or has previously met initial approval criteria (including continuity of care provisions where applicable); 2) Member is responding positively to therapy; 3) Member continues to receive moderately to highly emetogenic cancer chemotherapy (see Appendix D); 4) Continued therapy is prescribed in combination with a 5‑HT3 receptor antagonist (ondansetron preferred) and dexamethasone; 5) Member must use generic aprepitant or fosaprepitant unless contraindicated or clinically significant adverse effects are experienced; brand requests require justification or meet state exception per Appendix E.

Dose increases must not exceed specified regimen limits by formulation and age; see dosing tables for single‑dose and 3‑day maximums.

Initial Therapy — PONV

Prevention of Postoperative Nausea and Vomiting (PONV): Covered when ALL of the following are met

PONV initial criteria: 1) Request is for generic aprepitant capsules or Aponvie; 2) Prescribed for prevention of PONV prior to scheduled surgery; 3) Patient is >=18 years; 4) Member is scheduled to receive surgery; 5) Failure of a 5‑HT3 receptor antagonist (ondansetron preferred) at up to maximally indicated doses is required unless contraindicated or not tolerated (step therapy); note: Illinois HIM exception effective 1/1/2026 removes step therapy for formulary agents in that program.

Re‑authorization is not permitted for PONV; members must meet initial approval criteria.

Antiemetic regimen alignment

Covered when used consistent with guideline-directed antiemetic regimens based on emetogenic risk and product-specific FDA indications and dosing

Chemotherapy emetogenic risk and regimen alignment: Use aligns with emetogenic risk: NK1 receptor antagonists are recommended for high emetic risk chemotherapy in combination with 5‑HT3 receptor antagonists and dexamethasone; for moderate emetic risk chemotherapy, 5‑HT3 receptor antagonists and dexamethasone may be used with or without an NK1 antagonist; olanzapine may be included per guideline recommendations.HEC vs MEC per NCCN/ASCO

See Appendix D and product dosing for indication‑specific regimens.

Product and dosing match

Covered when product, dose, and age match FDA-approved indications and dosing regimens

Product-specific dosing: Aprepitant (Emend, Cinvanti, Aponvie) and fosaprepitant (Emend for injection, Focinvez) dosing must follow product labeling: examples include Emend capsules 125 mg PO day 1 then 80 mg PO days 2–3 for CINV, Cinvanti single‑dose 130 mg IV for HEC/MEC, Aponvie 32 mg IV for PONV, and fosaprepitant single‑dose 150 mg IV for adults; pediatric dosing and multi‑day regimens are specified per product.Refer to product dosing tables

Coverage is tied to indicated dosing by formulation and age; requests must document the specific product and dosing.

Requests for uses that are not FDA‑approved and are not specifically addressed in this policy are excluded unless the provider supplies sufficient documentation of efficacy and safety consistent with the applicable off‑label use policies (see CP CPA.09 for commercial, HIM.PA.154 for HIM, CP PMN.53 for Medicaid) or other evidence of coverage documents.

The policy lists known hypersensitivity to the drug as a contraindication. Prior authorization and coverage determinations will not be approved for members with documented hypersensitivity to aprepitant or fosaprepitant.

Concurrent use with pimozide is specifically contraindicated. Requests that would result in concomitant administration of pimozide and an NK1 antagonist should be denied per the contraindications noted in Appendix C.

Use of aprepitant or fosaprepitant for the treatment of established (ongoing) nausea and vomiting is not supported by the evidence in this policy. The products (including Aponvie, Emend, Cinvanti, and Focinvez) have not been studied for treatment of established nausea and vomiting, and chronic continuous administration of Emend oral suspension/capsules is not recommended.

The inclusion or exclusion of HCPCS/J codes in this policy is for informational purposes only and does not guarantee coverage. Providers must use current professional coding guidance when submitting claims; improper coding or submission that does not meet plan medical necessity criteria may result in claim denial.

Initial Therapy Criteria by Indication

Initial — CINV

Initial authorization criteria by indication and formulation

Initial — CINV: Request must be for listed products (generic aprepitant capsules, Emend, Cinvanti, Focinvez); indication must be prevention of chemotherapy‑induced nausea/vomiting; patient age must meet formulation minimums (Emend oral suspension/Emend for injection/Focinvez >=6 months; Emend capsules >=12 years; Cinvanti >=18 years); patient scheduled to receive moderately to highly emetogenic chemotherapy; prescribed in combination with a 5‑HT3 antagonist and dexamethasone; generic preferred unless contraindicated; brand requires additional justification or state exception (Appendix E); dosing must not exceed specified single‑dose or 3‑day regimens by age and formulation.

See dosing table for product‑specific single‑dose and multi‑day regimens and pediatric dosing.

Initial therapy dosing alignment: For HEC/MEC: follow product labeling for single‑dose or 3‑day regimens (examples: Cinvanti single‑dose 130 mg IV for HEC/MEC; Emend capsules 125 mg PO day 1 then 80 mg PO days 2–3; fosaprepitant single‑dose 150 mg IV for adults).Refer to product dosing table

Pediatric dosing provided separately in policy.

Continuation / Reauthorization Criteria

Continuation — CINV

Continuation therapy rules for aprepitant/fosaprepitant when used for CINV

Continuation: 1) Member must be currently receiving the medication via Centene benefit or have previously met initial approval criteria; 2) Member must be responding to therapy; 3) Member must continue to receive moderately to highly emetogenic chemotherapy; 4) Continued therapy must remain in combination with a 5‑HT3 antagonist and dexamethasone; 5) Generic aprepitant/fosaprepitant should be used unless contraindicated or not tolerated; brand requests require justification or meet state exception per Appendix E.

Dose increases for continuation must not exceed product‑specific limits by formulation and age.

Continuation/administrative notes

Historical and administrative continuation notes

Continuation/administrative notes: Template changes have been applied to the continued therapy section across policy reviews; coding and redirection to generic formulations have been updated historically (see policy history and coding implications).

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for aprepitant and fosaprepitant products (including Aponvie, Emend, Cinvanti, Focinvez, generic aprepitant and fosaprepitant). Providers must document the clinical indication, patient age, the emetogenicity of the chemotherapy regimen (HEC vs MEC), and concurrent use with a 5‑HT3 receptor antagonist and dexamethasone when applicable. Requests must include indication-specific dosing and product requested (e.g., HEC single-dose or MEC 3‑day regimens, pediatric dosing).

Provider must submit supporting documentation (office chart notes, lab results, medication history or other clinical information).
If request is for brand Emend, Focinvez, or Cinvanti, provider must document use of generic aprepitant or fosaprepitant unless contraindicated or clinically significant adverse effects are experienced (or an applicable bypass applies).
Prior authorization applies to listed HCPCS/J‑codes (see Coding Implications) and to unclassified drug submissions (e.g., J3490 historically).

Coding and Billing

Referenced HCPCS/J codesHCPCS

J1453	Injection,fosaprepitant,_L mg
J1456	Injection, fosaprepitant (Teva) not therapeutically equivalent to J1453_ Lmg
J0185	Injection_aprepitant mg
J8501	Aprepitant_oral_Smg_
C9145	Injection,aprepitant_(Aponvie) Lmg_
J1434	Injection,_fosaprepitant (Focinvez) lmg_

Maximum single-dose — examples

Emend for injection (fosaprepitant)Maximum single-dose: 150 mg (adult or pediatric single-dose).

Focinvez (fosaprepitant)Maximum single-dose: 150 mg (adult or pediatric single-dose).

Aponvie (aprepitant) — PONVMaximum single-dose: 32 mg (IV at induction of anesthesia).

Cinvanti (aprepitant) — single-dose for HEC/MECSingle-dose: 130 mg IV (maximum dose per single administration).

Emend (aprepitant) — oral formsCapsules: dosing per cycle with day 1 dose 125 mg and Days 2–3: 80 mg (per-cycle maximums per labeled regimen).

Step Therapy Rules

Requirement	Details
Step therapy requirement
Failure of a 5-HT3 receptor antagonist (ondansetron preferred) at up to maximally indicated doses is required unless contraindicated or not tolerated
Illinois HIM exception
For Illinois HIM requests, the step therapy requirements do not apply for formulary agents as of 1/1/2026 per IL HB 5395

Policy element	Application / Exception
Redirection / step therapy may be applied
Policy allows redirection/step therapy for applicable uses (e.g., requiring trial of a 5-HT3 antagonist prior to NK1 antagonist) where state rules permit
State-based prohibitions on redirection
Appendix E lists states that prohibit step therapy/redirection for stage IV or metastatic cancer; in those states the policy allows bypassing redirection per the appendix

Quantity Limits

Aprepitant / Fosaprepitant — product-specific single-dose and per-cycle maximums

Fosaprepitant (Emend for injection / Focinvez)Single‑dose: 150 mg IV over 20–30 minutes (adult and pediatric single‑dose maximum 150 mg).

Aponvie (aprepitant injectable emulsion)Single‑dose: 32 mg IV administered prior to induction for PONV (maximum 32 mg).

Cinvanti (aprepitant injectable)HEC/MEC single‑dose regimen: 130 mg IV on Day 1 (single‑dose maximum 130 mg for Cinvanti).

Emend (aprepitant oral)3‑day oral regimen: Day 1: 125 mg PO, Days 2–3: 80 mg PO (per‑cycle dosing limits per product labeling).

Site of Care / Formulation Settings

Note

Site of care: includes infusion center, hospital outpatient, office, and home

Policy includes coverage for inpatient/outpatient infusion products and oral formulations; injectable products are provided as single‑dose vials for infusion per product availability.

Site of care settings include infusion center, hospital outpatient, office, and home.
Product availability notes single‑dose vials for Emend for injection, Focinvez, and single‑dose injectable presentations for Cinvanti and Aponvie.

Background

Aprepitant and fosaprepitant are members of the neurokinin‑1 (NK1) receptor antagonist class of antiemetics. They are indicated for prevention of acute and delayed chemotherapy‑induced nausea and vomiting (CINV) in the setting of moderately and highly emetogenic chemotherapy and — for certain formulations — prevention of postoperative nausea and vomiting (PONV). These agents are typically used in combination with a 5‑HT3 receptor antagonist (ondansetron preferred in step therapy) and dexamethasone, with product‑specific single‑dose and multi‑day regimens and age‑dependent dosing specified by formulation.

Definitions

Highly emetogenic cancer chemotherapy (HEC)

Definition (HEC)Highly emetogenic cancer chemotherapy (HEC): chemotherapy regimens with high emetic risk for which NK1 receptor antagonists are recommended in combination with 5‑HT3 receptor antagonists and dexamethasone.

Examples of HEC agentsExamples include carmustine, cisplatin, cyclophosphamide ≥1,500 mg/m2, dacarbazine, mechlorethamine, streptozocin, fam‑trastuzumab deruxtecan‑nxki.

Clinical guidanceFor HEC, NK1 receptor antagonists are recommended as part of the antiemetic regimen; olanzapine may be added per guideline guidance.

Moderately emetogenic cancer chemotherapy (MEC)

Definition (MEC)Moderately emetogenic cancer chemotherapy (MEC): chemotherapy regimens with moderate emetic risk for which 5‑HT3 receptor antagonists and dexamethasone may be used, with or without an NK1 antagonist.

Provider Resources & Actions

Documentation Required

Required documentation: submit office notes, labs, or other supporting clinical information

Provider must submit supporting clinical documentation (such as office chart notes, lab results, or other clinical information) that the member meets all approval criteria.

Include documentation of prior therapies, dosing, and responses as applicable to the requested indication.

OpenPayer

Aprepitant and Fosaprepitant (NK1 receptor antagonists) coverage