Prior authorization required for some preferred generics

Dronabinol capsules (generic) and ondansetron injection (generic) are preferred products but require prior authorization; specific clinical criteria apply for approval (see drug-specific criteria for indication- and dose-based requirements).

Akynzeo requires prior failure of ondansetron + dexamethasone + aprepitant

Akynzeo (netupitant/palonosetron) may be approved only as an adjunct to dexamethasone for prophylaxis of chemotherapy‑induced nausea and vomiting when the member has tried and failed a regimen of ondansetron plus dexamethasone and aprepitant (Emend).

Initiate prior authorization via OptumRx; exceptions processed through PA

All prior authorization requests must be initiated through OptumRx; exceptions to the policy's coverage conditions are handled through the prior authorization process.

• Start PA by calling OptumRx at 1-866-525-5827.
• Use the PA process to request exceptions to coverage conditions.

Trimethobenzamide approval requires age ≥18 and failure/intolerance to ≥2 preferred products

Trimethobenzamide capsules (generic) are approvable for members 18 years and older for treatment of nausea and vomiting when the member has experienced inadequate emetic control or intolerance/allergy/contraindication to at least two preferred products.

• Member must be >= 18 years of age.
• Document inadequate control, allergy, contraindication, drug interaction, or intolerable side effects to >=2 preferred products.

Prior trial and failure of an ondansetron-containing regimen required

Approval of listed agents (e.g., dronabinol, ondansetron injection, Anzemet, granisetron) requires prior trial and failure of an ondansetron-containing regimen before authorization will be granted.

• For agents used for CINV or radiation-induced nausea, document prior trial and failure of an ondansetron‑based regimen as specified in the drug criteria.

Step requirement: trial and failure/intolerance to ≥2 preferred products for trimethobenzamide

Trimethobenzamide approval requires that the member has tried and failed (or has intolerance/allergy/contraindication to) at least two preferred products prior to authorization.

• Document trials and failures or reasons (intolerance, allergy, contraindication) for each of the two preferred products.

Written letter of medical necessity required for chlorpromazine oral concentrate

For chlorpromazine oral concentrate, the prescriber must submit a written letter of medical necessity explaining why preferred chlorpromazine tablets/injection and other oral liquids are not appropriate for the member.

Document need for injectable formulation with written letter of medical necessity

For dimenhydrinate injection and Tigan (trimethobenzamide) injection, the prescriber must submit a written letter of medical necessity that explains why the member requires an injectable formulation and why preferred injectable options are not appropriate.

Written letter of medical necessity required for ondansetron ODT 16 mg

For ondansetron ODT 16 mg, the prescriber must submit a written letter of medical necessity stating why preferred ondansetron products (generic ondansetron injection, ODT except 16 mg, tablets, and oral solution) are not appropriate.

Written letter of medical necessity required for prochlorperazine suppositories

For prochlorperazine suppositories, the prescriber must submit a written letter of medical necessity stating why preferred prochlorperazine tablets and injection are not appropriate for the member.

Written letter of medical necessity required for promethazine 50 mg suppository

For promethazine 50 mg suppositories, the prescriber must submit a written letter of medical necessity explaining why the preferred promethazine 25 mg suppository is not appropriate for the member.

Provide chemotherapy regimen documentation to support exceeding QLL for select agents

To support authorization to exceed Quantity Level Limits (QLL) for Anzemet, Aprepitant (capsules/pack), Emend suspension, and Granisetron, documentation of the member's chemotherapy regimen frequency and duration must be submitted.

• Include chemotherapy regimen frequency/duration in PA documentation to justify exceeding QLL.

Bill physician‑administered drugs through DCH physician services program (not outpatient pharmacy)

Medications administered in a physician's office or clinic must be billed through the DCH physician services program rather than the outpatient pharmacy program; billing the incorrect program may result in denial.

• Information about the physician services program is available at www.mmis.georgia.gov.

Requests exceeding QLL may be denied without meeting PA criteria and documentation

Requests that exceed established Quantity Level Limits (QLL) may be denied unless the prior authorization criteria for exceeding QLL are met and appropriate supporting documentation is provided.

• For ondansetron, documentation of chemotherapy regimen frequency/duration or diagnosis of hyperemesis gravidarum may support exceeding QLL.

Administer specified injectable formulations in home or long‑term care facility

Certain injectable formulations (e.g., ondansetron and granisetron injectables where specified) must be administered in the member's home or in a long‑term care facility as stated in the drug criteria.

• Confirm site‑of‑care (home or long‑term care facility) in PA documentation when required.