Clinical Policy: Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV)
Defines medical necessity criteria, initial and continued therapy requirements, dosing limits, allowed indications, documentation and coding implications for oral Akynzeo capsules and IV Akynzeo (fosnetupitant/palonosetron) for prevention of chemotherapy-induced nausea and vomiting in adults across commercial, HIM and Medicaid lines of business.
Added step therapy bypass for Illinois HIM per IL HB 5395 and updated Appendix E language and exception for Tennessee.
Added requirement that member is scheduled to receive moderately to highly emetogenic cancer chemotherapy for initial approval.
Removed distinction between oral and IV versions for moderate vs high emetogenic risk per NCCN 1.2021 guidelines.
Added coding implications and J-codes for oral and IV formulations.