Currentharvard pilgrim health carePolicy N/A

Akynzeo (netupitant/palonosetron) prior authorization

Prior authorization policy for coverage of Akynzeo (netupitant/palonosetron) for prevention of chemotherapy-associated nausea and vomiting in adult members of Harvard Pilgrim Health Care commercial and related products.

Policy Summary

Payerharvard pilgrim health care

PolicyAkynzeo (netupitant/palonosetron) prior authorization

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateAug 12, 2025

Next Review DateN/A

Key ActionObtain prior authorization from the plan before dispensing Akynzeo and include documentation supporting indication and chemotherapy emetogenicity per NCCN.

SourceLink

POLICY UPDATE CHANGES

Administrative update to add limitation statement for non-formulary medication request.

Adultsage group covered

Chemo CINVindication

Dexamethasoneco-therapy requirement

Mod–Highemetogenicity requirement

Nonecodes listed

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Coverage Criteria for Akynzeo (netupitant/palonosetron)

Coverage Criteria

The plan may authorize coverage of Akynzeo when ALL of the following criteria are met:

Akynzeo coverage criteria: 1. Akynzeo is being requested for the prevention of nausea and vomiting associated with cancer chemotherapy

Akynzeo coverage criteria: 2. Patient is 18 years of age or older>= 18 years

Akynzeo coverage criteria: 3. Patient is receiving moderately to highly emetogenic intravenous chemotherapy as defined by NCCN Clinical Practice Guidelines for Antiemesis

Follow NCCN for emetogenicity classification

Akynzeo coverage criteria: 4. Akynzeo will be taken with dexamethasone

For non-formulary medication requests, providers must follow the Pharmacy Medical Necessity Guidelines for Formulary Exceptions and submit a formulary exception request to the plan as indicated. See the plan’s formulary-exception process for required documentation and submission instructions.

Use of Akynzeo outside the scope of this policy is not supported. Specifically, this policy does not support use for indications other than the prevention of nausea and vomiting associated with cancer chemotherapy, nor does it support use when the drug will not be taken with the required co-therapy of dexamethasone or when dosing/setting in the request does not match the coverage criteria.

Initial Therapy

Initial coverage when used for prevention of chemotherapy-associated nausea/vomiting

Initial therapy: See Coverage Criteria: adult patient; indication is prevention of chemotherapy-associated nausea/vomiting; receiving moderately to highly emetogenic IV chemotherapy per NCCN; will be taken with dexamethasone

Refer to prescribing information and NCCN guidelines

Codes and Age

Codesmixed

No codes listed

Age

Age requirement>= 18 years

ScopeApplies to members being considered for Akynzeo (netupitant/palonosetron) prior authorization

Documentation implicationPatient age must be documented in the prior authorization request

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Akynzeo (netupitant/palonosetron). Submit prior authorization requests to the plan. Fax: 617-673-0988.

Applies to Harvard Pilgrim Health Care Commercial products
Also applies to Tufts Health Plan Commercial products and Tufts Health Direct (QHP)

Note

Provider Administrative Note

As a condition of payment, ensure that prior authorization has been obtained when required. Providers may not always be the party who requests authorization but are responsible for confirming authorization status prior to claim submission.

Definitions

Akynzeo — Key drug definition and indication summary.

Drug name (generic)Netupitant/palonosetron

Brand nameAkynzeo

Mechanism/combinationFixed‑combination NK1 receptor antagonist (netupitant) and 5‑HT3 receptor antagonist (palonosetron)

Indication summaryOral Akynzeo in combination with dexamethasone is indicated for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of cancer chemotherapy; policy limits to prevention of chemotherapy‑associated nausea/vomiting in adults

Moderately to highly emetogenic IV chemotherapy — definition per NCCN

Definition sourceClassification per NCCN Clinical Practice Guidelines for Antiemesis (NCCN Antiemesis)

Background

Akynzeo is a fixed oral combination of netupitant (a neurokinin-1 receptor antagonist) and palonosetron (a 5-HT3 receptor antagonist) indicated, when used with dexamethasone, for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of cancer chemotherapy. Palonosetron primarily addresses the acute phase while netupitant contributes to prevention of both acute and delayed phases.

Policy Summary

Payerharvard pilgrim health care

PolicyAkynzeo (netupitant/palonosetron) prior authorization

Policy CodePolicy N/A

Change TypeAdministrative update

Effective DateAug 12, 2025

Next Review DateN/A

Key ActionObtain prior authorization from the plan before dispensing Akynzeo and include documentation supporting indication and chemotherapy emetogenicity per NCCN.

SourceLink

On This Page

Documentation Required

Documentation Expectations

Documentation submitted with the prior authorization request must support the indication and chemotherapy regimen details. At minimum include: patient age, diagnosis indicating prevention of chemotherapy-associated nausea and vomiting, documentation that the chemotherapy regimen is moderately to highly emetogenic per NCCN, and that Akynzeo will be administered with dexamethasone. Prior authorization is a condition of payment.

Include chemotherapy regimen name and emetogenicity source (e.g., NCCN guideline reference)
Document plan for concomitant dexamethasone use
Confirm patient is ≥ 18 years of age

Denial Risk

Denial Risk if Criteria Not Met

Requests that do not meet all listed criteria may be denied. Denial risk factors include: patient under 18 years of age, indication other than prevention of chemotherapy-associated nausea and vomiting, chemotherapy regimen not classified as moderately to highly emetogenic per NCCN, or lack of planned dexamethasone co-therapy.

Emetogenicity requiredModerately to highly emetogenic intravenous chemotherapy as defined by NCCN

Policy applicationAkynzeo coverage requires the member is receiving IV chemotherapy classified as moderately or highly emetogenic per NCCN guidance

Reference guidance versionNCCN Clinical Practice Guidelines in Oncology, Antiemesis Version 2.2025