CurrentMass General Brigham Health PlanPolicy N/A

Focinvez (fosaprepitant) — Prior Authorization and Coverage Criteria

This policy governs prior authorization, quantity limits, and coverage criteria for Focinvez (fosaprepitant) under Mass General Brigham Health Plan pharmacy and medical benefits for members receiving chemotherapy-associated nausea and vomiting prevention.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFocinvez (fosaprepitant) — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeReferences updatedno clinical changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Focinvez for CINV and document clinical rationale for use instead of fosaprepitant injection (Emend).

SourceLink

POLICY UPDATE CHANGES

References updated; no clinical changes.

Policy created and adopted MassHealth criteria; Focinvez requires prior authorization under medical and pharmacy benefits.

6 monthstypical approval duration

<2/28drequested quantity threshold

>=6 momin age

HEC/MECapproved emetogenicity

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Initial Authorization

Authorization may be granted when ALL of the following are met:

Initial authorization criteria: Member has a diagnosis of chemotherapy-induced nausea and vomiting (CINV).

From policy: diagnosis requirement.

Initial authorization criteria: Prescriber provides clinical rationale for the use of Focinvez instead of fosaprepitant injection (Emend).

Policy requires documented rationale for using Focinvez vs Emend.

Initial authorization criteria: Requested quantity is less than 2 units per 28 days.< 2 units/28 day

Quantity limit per policy.

Initial Therapy

Initial therapy: Indication consistent with FDA label: prevention of acute and delayed nausea and vomiting associated with HEC (including high-dose cisplatin) and delayed nausea and vomiting associated with MEC in patients aged 6 months and older; member has a diagnosis of CINV; prescriber provides clinical rationale for the use of Focinvez instead of fosaprepitant injection (Emend); requested quantity is < 2 units per 28 days.see text

Derived from Overview and authorization criteria.

No specific exclusions are listed for Focinvez in this policy. For members who are new to the plan and already receiving the requested medication, authorizations will be reviewed case-by-case. Product supplies obtained as samples or through a manufacturer’s patient assistance program are excluded from the routine review/authorization statement and should not be treated as part of the member’s documented therapy for coverage purposes.

Initial Therapy

Initial therapy: Patient meets the labeled indication: prevention of acute and delayed CINV for HEC and delayed CINV for MEC in patients ≥ 6 months; clinical rationale documented for choosing Focinvez over fosaprepitant injection (Emend); requested quantity < 2 units/28 days.see text

Restates initial therapy conditions with age and indication.

Continuation of Therapy

Continuation Therapy

Continuation of therapy

Continuation criteria: Resubmission by the prescriber infers a positive clinical response to therapy.

No objective response criteria required per policy.

Continuation of Therapy

Continuation

Resubmission inference: Resubmission by prescriber infers positive response to therapy; approvals are granted for 6 months.6 months

Approval duration per policy limitations.

Quantity Limits

Focinvez (fosaprepitant) — quantity limit

DrugFocinvez (fosaprepitant)

Quantity limit< 2 units per 28 days

ContextRequired for authorization; part of the Initial Authorization criteria

Focinvez (fosaprepitant) — approval duration

Approval duration6 months

Applies toApprovals for Focinvez when authorized

Renewal implicationResubmission by prescriber will infer positive response; approvals granted for successive 6-month periods as appropriate

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Focinvez (fosaprepitant) under both the medical benefit and the pharmacy benefit.

Applies to Medical Benefit and Pharmacy Benefit
Contact (Medical & Specialty Medications): Phone 877-519-1908, Fax 855-540-3693
Contact (Non-Specialty/All Plans): Phone 800-711-4555, Fax 844-403-1029

Documentation Required

Authorization Criteria

Authorization may be granted when ALL of the following are met: diagnosis of chemotherapy-induced nausea and vomiting (CINV); clinical rationale provided for use of Focinvez instead of fosaprepitant injection (Emend); and requested quantity is less than 2 units per 28 days. Authorization for members new to the plan who are currently receiving the medication may be reviewed on a case‑by‑case basis (excludes product obtained as samples or via manufacturer patient assistance programs).

Diagnosis: Chemotherapy-induced nausea and vomiting (CINV)
Clinical rationale comparing Focinvez to fosaprepitant injection (Emend) must be documented
Requested quantity < 2 units per 28 days
New-to-plan members currently receiving therapy: case-by-case review (excluding samples or manufacturer patient assistance programs)

Step Therapy

Step Therapy Note

Step therapy is in effect for this agent; however, explicit step-failure criteria must be documented by the prescriber when applicable. If the plan requires failure of an alternative agent prior to approval, provide documentation of trial and reason for failure or intolerance.

Step therapy applies — prescriber must document trials and failures or intolerance of required prior agents when relevant
If requesting an exception to step therapy, include clinical rationale supporting immediate use of Focinvez

Documentation Required

Required Documentation

Provide clinical rationale and supporting documentation when requesting Focinvez instead of fosaprepitant injection (Emend). Missing or incomplete documentation may result in denial.

Include member diagnosis, prior therapies tried (with dates and outcomes), and reason Focinvez is preferred over fosaprepitant injection (Emend)
Include requested dosing and quantity (units/28 days) — requests ≥ 2 units/28 days may be denied
For members new to the plan, include verification they were receiving the medication (exclude samples/PAP)

Denial Risk

Reasons Authorization May Be Denied

Authorizations may be denied for lack of clinical rationale, missing required documentation, failure to meet quantity limits, or failure to document step therapy trials/step‑failure when required.

No documentation of diagnosis of CINV
No clinical rationale for use instead of fosaprepitant injection (Emend)
Requested quantity ≥ 2 units per 28 days
Missing documentation of prior agent trials or reasons for step‑therapy exception
Incomplete records for members new to plan (no evidence of active therapy; samples or PAP only)

Program type	Step therapy requirement
Step Therapy	Listed as a program type in the policy, but no specific step-fail requirements or explicit step criteria are provided in this document.

Definitions

HEC/MEC — emetogenicity categories

HEC definition (context)Highly emetogenic chemotherapy — includes regimens such as high-dose cisplatin used in prevention of acute and delayed nausea and vomiting

MEC definition (context)Moderately emetogenic chemotherapy — regimens associated with delayed nausea and vomiting for which Focinvez is indicated

Indication ageIndicated for prevention of CINV in patients aged 6 months and older

Use with other agentsFocinvez is used in combination with other antiemetic agents for HEC and MEC indications

Background

Fosaprepitant (Focinvez) is an NK1 receptor antagonist indicated, in combination with other antiemetics, to prevent acute and delayed nausea and vomiting associated with highly emetogenic chemotherapy (HEC) and delayed nausea and vomiting associated with moderately emetogenic chemotherapy (MEC). The product is approved for adults and pediatric patients aged 6 months and older.

Revision History

2024-10-09creation

Policy created for P&T and adopted MassHealth criteria; Focinvez requires prior authorization under both the medical benefit and the pharmacy benefit; policy created for medical benefit posting on MGBHP web; effective 2024-11-12.

2025-08-13annual_reviewLatest

Reviewed and updated for P&T as part of the annual UM review; references updated with no clinical changes; new effective date 2025-09-01.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFocinvez (fosaprepitant) — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeReferences updatedno clinical changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Focinvez for CINV and document clinical rationale for use instead of fosaprepitant injection (Emend).

SourceLink

On This Page

OpenPayer

Focinvez (fosaprepitant) — Prior Authorization and Coverage Criteria

Coverage Criteria

Initial Therapy

Continuation of Therapy

Coding & Requested Quantity

Quantity Limits

Provider Actions & Requirements

Step Therapy

Definitions

Background

Revision History