Akynzeo (netupitant/palonosetron) prior authorization
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Prior authorization criteria for coverage of Akynzeo (netupitant/palonosetron) for prevention of chemotherapy-induced nausea and vomiting in adult members of Harvard Pilgrim and Tufts commercial products.
Administrative update to add limitation statement for non-formulary medication request.
Administrative update to remove Carelink from Medical Necessity Guideline template.
Coverage Criteria for Akynzeo (netupitant/palonosetron)
Clinical Guideline Coverage Criteria
Covered when ALL of the following are met
Based on FDA indication and NCCN guidance
Adults only per FDA-approved indication
Refer to NCCN for emetogenicity classification
Per FDA-approved indication — Akynzeo indicated with dexamethasone
For requests involving a medication that is not on the plan formulary, the provider must follow the plan’s formulary exception process. Submit a formulary exception request to the plan per the Pharmacy Medical Necessity Guidelines for Formulary Exceptions so the non-formulary Akynzeo request can be reviewed for coverage.
Initial Therapy
Initial Therapy
Initial coverage criteria
Aligns with FDA-approved indication and NCCN guidance
Provider Actions and Prior Authorization Requirements
Prior authorization required
Prior authorization is required for Akynzeo; authorization may be granted when all clinical criteria are met for prevention of nausea and vomiting associated with cancer chemotherapy.
No step therapy required
No step therapy requirements are specified in this guideline.
Required clinical documentation
Documentation should support that Akynzeo is prescribed for prevention of acute and delayed nausea and vomiting associated with initial or repeat courses of cancer chemotherapy, that the patient is 18 years of age or older, that the chemotherapy is moderately to highly emetogenic per NCCN, and that Akynzeo will be taken with dexamethasone.
Denial triggers for incomplete criteria
Requests that do not meet all clinical criteria may be denied.
- Not prescribed for prevention of chemotherapy-associated nausea and vomiting
- Patient under 18 years of age
- Chemotherapy is not moderately to highly emetogenic per NCCN
- Akynzeo not being taken with dexamethasone
Coding
| No codes listed |
Definitions
Background
Akynzeo is an oral fixed combination of netupitant (an NK1 receptor antagonist) and palonosetron (a 5‑HT3 receptor antagonist) indicated, in combination with dexamethasone, for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of cancer chemotherapy, including moderately to highly emetogenic regimens. Palonosetron primarily prevents acute-phase events while netupitant contributes to prevention of both acute and delayed-phase events, aligning with guideline-recommended antiemesis strategies.
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