Antiemetics – Serotonin Receptor Antagonists (Oral and Transdermal) Drug Quantity Management - Per Rx - (CNF189)

Coverage summary

Scope: This Drug Quantity Management policy covers oral and transdermal serotonin (5-HT3) receptor antagonists (granisetron and ondansetron products) administered under Cigna health benefit plans and defines per-prescription retail and home-delivery maximum quantities, medical-necessity exceptions (overrides), default approval duration, and automation for cancer-related chemotherapy claims. Default approvals are for 1 year. Per-prescription maximums include, for example, granisetron 1 mg: retail 6 tablets / home delivery 18 tablets; Sancuso patch: retail 1 patch / home delivery 3 patches; ondansetron 4/8 mg tablets or ODT: retail 9 tablets / home delivery 27 tablets; ondansetron 16 mg ODT (branded): retail 2 tablets / home delivery 6 tablets; and ondansetron oral solution: retail 100 mL / home delivery 300 mL. Overrides and higher per-dispensing volumes are specified in the criteria (e.g., chemo-related multi-course exceptions). Claims with a prior 180-day prescription for a cancer medication (Appendix A STC list) or cancer ICD-10 codes will adjudicate automatically to generate approval.

Covered product count: 9 products/strengths listed in the policy.

Per-dispensing quantity thresholds

Granisetron - Retail max per Rx6 tablets

Granisetron - Home delivery max per Rx18 tablets

Sancuso (transdermal) - Retail max per Rx1 patch

Sancuso (transdermal) - Home delivery max per Rx3 patches

Ondansetron 4/8 mg (tablet/ODT) - Retail max per Rx9 tablets

Ondansetron 4/8 mg (tablet/ODT) - Home delivery max per Rx27 tablets

Ondansetron 16 mg ODT (branded) - Retail max per Rx2 tablets

Ondansetron 16 mg ODT (branded) - Home delivery max per Rx6 tablets

Ondansetron oral solution - Retail max per Rx100 mL

Ondansetron oral solution - Home delivery max per Rx300 mL

General policy statement

General Policy Statement

All approvals are provided for 1 year unless otherwise noted. If Drug Quantity Management rule is not met at point of service, coverage determined by criteria below. Exceptions covered as medically necessary when following criteria are met; any other exception is not medically necessary.

General Policy

Duration and adjudication: Approvals provided for 1 year in duration unless otherwise noted
Point-of-service rule: If quantity limit not met at point of service, coverage determined by the specific criteria for each product

Definitions:

• MEC — Moderate emetogenic chemotherapy. (term defined in dosing abbreviations table).

• HEC — Highly emetogenic chemotherapy. (term defined in dosing abbreviations table).

Granisetron (1 mg tablets) — Quantity limit overrides

Granisetron 1 mg tablets (generic only) - Overrides

Exceptions to quantity limits are covered when ANY of the following are met:

Granisetron overrides

Chemotherapy multi-course: Patient receiving granisetron for prevention of nausea and/or vomiting associated with multiple courses or multiple days of cancer chemotherapy within 1 month
Approve requested quantity, not to exceed 60 tablets per dispensing at retail or 180 tablets per dispensing at home delivery
Specified non-chemotherapy conditions: Patient receiving granisetron for treatment of specified conditions (radiation-induced emesis; delayed nausea and/or vomiting (>24 hours following chemotherapy or radiation); as needed after chemotherapy; anticipatory nausea/vomiting; vertigo/motion-induced nausea/vomiting; opioid-induced nausea/vomiting; postoperative nausea/vomiting; pregnancy-induced nausea/vomiting; drug-induced non-chemotherapy nausea/vomiting; other etiologies including idiopathic)
Approve requested quantity not to exceed 60 tablets per dispensing at retail or 180 tablets per dispensing at home delivery (allow up to 2 tablets/day) for 6 months

Sancuso transdermal system — Quantity limit overrides

Sancuso 34.3 mg transdermal system - Overrides

Exceptions to quantity limits are covered when the following is met:

Sancuso override: Patient receiving Sancuso for prevention of nausea and/or vomiting associated with multiple courses or multiple days of cancer chemotherapy within 1 month

Approve requested quantity not to exceed 4 patches per dispensing at retail or 16 patches per dispensing at home delivery

Operational note: Approvals provided for 1 year unless otherwise noted; when adjudicating for cancer therapy, automation may approve based on prior cancer medication claim or cancer ICD-10 codes

Ondansetron 4 mg (tablets/ODT) — Quantity limit overrides

Ondansetron 4 mg tablets and 4 mg orally disintegrating tablets (generic only) - Overrides

Exceptions to quantity limits are covered when ANY of the following are met:

Ondansetron 4 mg tablet/ODT chemotherapy: Prevention of nausea and/or vomiting associated with multiple courses or multiple days of chemotherapy within 1 month

Approve requested quantity not to exceed 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery

Ondansetron 4 mg tablet/ODT radiation: Prevention of radiation-induced nausea and/or vomiting associated with multiple courses or multiple days of radiation within 1 month

Approve requested quantity not to exceed 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery

Ondansetron 4 mg tablet/ODT pregnancy: Pregnancy-induced nausea and/or vomiting

Ondansetron 8 mg (tablets/ODT) — Quantity limit overrides

Ondansetron 8 mg tablets and 8 mg orally disintegrating tablets (generic only) - Overrides

Exceptions to quantity limits are covered when ALL of the following are met:

Age requirement: Patient is ≥ 12 years of age

Chemotherapy prevention: Receiving ondansetron for prevention of nausea and/or vomiting associated with multiple courses or multiple days of chemotherapy within 1 month

Approve requested quantity not to exceed 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery

Radiation prevention: If receiving for prevention or treatment of radiation-induced nausea and/or vomiting

Approve quantity not to exceed 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery

Ondansetron oral solution — Quantity limit overrides

Ondansetron 4 mg/5 mL oral solution (generic only) - Overrides

Exceptions to quantity limits are covered when ANY of the following are met (age-specific volumes and conditions):

Oral solution chemotherapy prevention: Prevention of nausea and/or vomiting associated with multiple courses or multiple days of chemotherapy within 1 month

Patients ≥ 12 years: approve up to 900 mL retail / 2,700 mL home delivery (accommodates up to 30 mL [24 mg]/day); patients ≤ 11 years: approve up to 450 mL retail / 1,350 mL home delivery (accommodates up to 15 mL [12 mg]/day); round up to whole package sizes

Oral solution radiation prevention: Prevention of radiation-induced nausea and/or vomiting associated with multiple courses or multiple days of radiation within 1 month

Patients ≥ 12 years: approve up to 900 mL retail / 2,700 mL home delivery for 6 months (accommodates 30 mL [24 mg]/day); patients ≤ 11 years: approve up to 450 mL retail / 1,350 mL home delivery for 6 months; round up to whole package sizes

Oral solution treatment ≥12:

Ondansetron 16 mg ODT (branded) — Overrides

Ondansetron 16 mg orally disintegrating tablets (branded) - Overrides

No overrides recommended

No overrides recommended for ondansetron 16 mg orally-disintegrating tablets (branded)

Retail max 2 / home delivery max 6 per Rx

Ondansetron 16 mg ODT - Retail low per-Rx threshold2 tablets

Ondansetron 16 mg ODT - Home delivery low per-Rx threshold6 tablets

Applicable products / codes

Product list (drug names/strengths covered by policy)mixedCovered

granisetron 1 mg tablets	generic granisetron tablets - retail max 6 tablets per Rx; home delivery max 18 tablets per Rx (overrides allow up to 60/180)
Sancuso 34.3 mg (3.1 mg/24 hr) transdermal system	granisetron transdermal patch - retail max 1 patch per Rx; home delivery max 3 patches per Rx (overrides allow up to 4/16 for chemo)
ondansetron 4 mg tablets	generic ondansetron 4 mg tablets - retail max 9 tablets per Rx; home delivery max 27 tablets per Rx (overrides up to 90/270)
ondansetron 8 mg tablets	generic ondansetron 8 mg tablets - retail max 9 tablets per Rx; home delivery max 27 tablets per Rx (overrides similar to 4 mg with age criteria)
ondansetron 4 mg orally disintegrating tablets	generic ondansetron ODT 4 mg - retail max 9 per Rx; home delivery 27 per Rx (overrides up to 90/270)
ondansetron 8 mg orally disintegrating tablets	generic ondansetron ODT 8 mg - retail max 9 per Rx; home delivery 27 per Rx (overrides similar to 8 mg tablets)
ondansetron 16 mg orally disintegrating tablets (branded)	branded ondansetron 16 mg ODT - retail max 2 tablets per Rx; home delivery max 6 tablets per Rx; no overrides recommended
ondansetron oral solution 4 mg/5 mL	generic oral solution - retail max 100 mL per Rx; home delivery max 300 mL per Rx (overrides detailed by age/indication; adult chemo up to 900/2700 mL; pediatric limits lower)

Provider actions and operational rules

Prior Authorization

Quantity limit override requests

When the requested quantity exceeds the per‑Rx retail or home‑delivery maximum, submit indication documentation that the patient meets the specific override criteria (for example: multiple courses or multiple days of cancer chemotherapy within 1 month; specified treatment indications such as radiation‑induced emesis, delayed nausea/vomiting, pregnancy‑induced nausea/vomiting, postoperative nausea/vomiting, opioid‑ or drug‑induced nausea/vomiting; or patient age criteria where applicable). Approvals are provided for 1 year in duration unless otherwise noted.

Billing Rule

Adjudication automation for cancer therapy

If there is a prior 180‑day prescription claim for a cancer medication (see Appendix A STC list) or an available cancer ICD‑10 code (Appendix B: C00.*‑D09.*, D3A.*‑D48.*, E34.0*, Q85.0*), the claim will adjudicate automatically to generate approval of the requested medication.

Clinical references and background

Background: This policy describes indications and dosing for oral and transdermal 5-HT3 receptor antagonists (granisetron and ondansetron) and sets drug quantity management limits per prescription with specified medical-necessity exceptions. It references product prescribing information for product-specific dosing and pediatric statements; those product prescribing information references are listed in the evidence section.

References: Product prescribing information — Granisetron tablets [prescribing information], Breckenridge; January 2024. Sancuso transdermal system [prescribing information], Cumberland; July 2024. Ondansetron tablets and orally disintegrating tablets [prescribing information], Glenmark; August 2025. Ondansetron oral solution [prescribing information], Amneal; September 2025. Ondansetron orally disintegrating tablets [prescribing information], Lifsa; June 2024.

Revision history

2026-04-22clarifiedLatest

Throughout the policy, wording changed: 'nausea and vomiting' modified to 'nausea and/or vomiting' (clarified). Additional context: editorial wording change applied across indications and criteria to reflect 'nausea and/or vomiting'.

2025-09-24added

Automation added to adjudication: prior 180-day prescription claim for a cancer medication (Appendix A STC list) or available cancer ICD-10 codes (Appendix B) will adjudicate to generate approval (added). Additional context: operational automation uses Appendix A STC list and Appendix B cancer ICD-10 ranges to auto-approve when detected.

2024-09-11