mhn aprepitant fosaprepitant Coverage Update

Coverage Criteria

Initial Therapy — CINV

Covered when ALL of the following are met for prevention of chemotherapy-associated nausea and vomiting:

CINV initial approval: 1) Request is for generic aprepitant capsules, Emend, Cinvanti, or Focinvez; 2) Prescribed for the prevention of chemotherapy-induced nausea/vomiting; 3) Member meets one of the following age criteria: (a) Emend oral suspension, fosaprepitant (Emend for injection), or Focinvez: age ≥ 6 months; (b) Aprepitant (Emend) capsules: age ≥ 12 years; (c) Cinvanti: age ≥ 18 years; 4) Member is scheduled to receive moderately to highly emetogenic cancer chemotherapy (see Appendix D); 5) Prescribed in combination with a serotonin (5-HT3) receptor antagonist (ondansetron is preferred) and dexamethasone; 6) If request is for brand Emend, Focinvez, or Cinvanti, one of the following: (a) member must use generic aprepitant or fosaprepitant unless contraindicated or clinically significant adverse effects are experienced; or (b) request is for treatment associated with cancer for a State with regulations against step therapy in certain oncology settings (see Appendix E); 7) Dose does not exceed product-specific limits: (a) Emend oral suspension or capsules: Day 1 125 mg then Days 2–3 80 mg per chemotherapy cycle (pediatric: if age ≥6 months and <12 years: Day1 3 mg/kg then Days2–3 2 mg/kg); (b) Emend for injection / Focinvez: single-dose regimen Day1 150 mg (pediatric weight-based alternatives) or 3-day regimen with Day1 115 mg (pediatric dosing as specified); (c) Cinvanti: single-dose 130 mg on Day1 for HEC and MEC or 3-day regimen Day1 100 mg for MEC.see node text

See Appendix D for emetogenicity list.

Initial Therapy — PONV

Covered when ALL of the following are met for prevention of postoperative nausea and vomiting (PONV):

PONV initial approval: 1) Request is for generic aprepitant capsules or Aponvie; 2) Prescribed for the prevention of PONV; 3) Age ≥ 18 years; 4) Member is scheduled to receive surgery; 5) Failure of a 5-HT3 receptor antagonist (ondansetron is preferred) at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced (Illinois HIM: step therapy requirements do not apply for formulary agents as of 1/1/2026 per IL HB 5395); 6) Dose does not exceed product limits: generic aprepitant capsules 40 mg once; Aponvie 32 mg once.see node text

For Illinois HIM requests, step therapy exemptions apply per IL HB 5395.

Continuation Therapy — CINV

Covered when ALL of the following are met for continued therapy for CINV:

CINV continuation: 1) Member currently receiving medication via Centene benefit or member has previously met initial approval criteria, or member is receiving medication and is enrolled in a state/product with continuity of care regulations; 2) Member is responding positively to therapy; 3) Member continues to receive moderately to highly emetogenic cancer chemotherapy (see Appendix D); 4) Prescribed in combination with a 5-HT3 receptor antagonist (ondansetron is preferred) and dexamethasone; 5) If request is for brand Emend, Focinvez, or Cinvanti, one of the following: (a) member must use generic aprepitant or fosaprepitant unless contraindicated or clinically significant adverse effects are experienced; or (b) request is for treatment associated with cancer for a State with regulations against step therapy in certain oncology settings (see Appendix E); 6) If request is for a dose increase, new dose does not exceed the product-specific dosing limits as specified for initial therapy (Emend, Emend for injection/Focinvez, Cinvanti).see node text

Approval duration aligned with projected duration of chemotherapy.

Guideline-driven coverage by emetogenic risk

Coverage is guided by emetogenic risk and guideline-recommended regimens; NK1 receptor antagonists (aprepitant/fosaprepitant) are recommended in the following scenarios per NCCN/ASCO:

Moderately emetogenic chemotherapy (MEC): NK1 receptor antagonists may be used in combination with a 5-HT3 receptor antagonist and dexamethasone; olanzapine may be used in combination with palonosetron and dexamethasone.

Examples of MEC agents listed in policy (e.g., carboplatin, irinotecan, oxaliplatin).

Highly emetogenic chemotherapy (HEC): NK1 receptor antagonists are recommended in combination with 5-HT3 receptor antagonists and dexamethasone; olanzapine may also be used in combination with these agents.

Examples of HEC agents listed (e.g., cisplatin, cyclophosphamide >1500 mg/m2).

Breakthrough emesis: For breakthrough emesis, add an agent from a different drug class to the current regimen; an NK1 receptor antagonist may be added to prophylaxis in the next cycle if not previously included.

Drug classes include atypical antipsychotics, benzodiazepines, cannabinoids, phenothiazines, 5-HT3 antagonists, steroids, etc.

Product dosing-aligned coverage criteria

Product-specific dosing indications and limits inform appropriate use:

Cinvanti (IV aprepitant): HEC or MEC single-dose regimen: 130 mg IV on Day 1; MEC 3-day regimen: 100 mg IV on Day 1 for applicable regimens. Maximum single-dose 130 mg.Max single-dose 130 mg

Cinvanti dosing per product labeling.

Emend (oral aprepitant): Capsules: 125 mg PO Day 1, then 80 mg PO Days 2 and 3 per chemotherapy cycle; oral suspension pediatric weight-based dosing: Day1 3 mg/kg then Days2–3 2 mg/kg.Per-cycle Day1: 125 mg; Days2-3: 80 mg

Covers oral capsule/suspension regimens when aligned with prescribing information.

Fosaprepitant (Emend for injection / Focinvez): HEC or MEC single-dose: 150 mg IV on Day 1 (adult); pediatric weight-based dosing provided (e.g., 12–17 years 150 mg IV; 2–<12 years 4 mg/kg IV; 6 months–<2 years 5 mg/kg IV); multi-day regimens include Day1 115 mg for certain pediatric regimens. Maximum single-dose 150 mg.

Coverage is not authorized for non‑FDA approved indications that are not explicitly addressed by this policy unless the provider submits sufficient documentation of efficacy and safety in accordance with applicable off‑label use policies (for example, CP.CPA.09, HIM.PA.154, CP.PMN.53) or other evidence of coverage documents.

Contraindications include known hypersensitivity to the product and concurrent use with pimozide. These contraindications are listed in Appendix C of the policy and should be reviewed prior to prescribing.

Use of aprepitant/fosaprepitant products is for prophylaxis; these agents have not been studied for treatment of established (active) nausea and vomiting. Additionally, chronic continuous administration of Emend oral suspension or capsules is not recommended and is not covered beyond the prophylactic regimens described in the policy.

No boxed warnings are reported for the referenced aprepitant or fosaprepitant products in Appendix C of the policy.

Covered Regimens and Dosing

Regimen	Indication	Required Concomitant Agents	Coverage Status
NK1 receptor antagonist (aprepitant or fosaprepitant) in combination with 5-HT3 receptor antagonist and dexamethasone
Prophylaxis for chemotherapy-induced nausea and vomiting (CINV) associated with high emetic risk chemotherapy
5-HT3 receptor antagonist (e.g., ondansetron preferred) and dexamethasone
Covered when used per ASCO/NCCN recommendations for HEC (see Appendix D)

Product / Formulation	FDA-indication & Dosing (selected)	Clinical Context / Notes	Coverage Status
Aponvie (IV aprepitant)
Indication: Prevention of postoperative nausea and vomiting (PONV). Dosing: 32 mg IV prior to induction of anesthesia; maximum dose 32 mg.
Covered for prevention of PONV when FDA-approved dosing is used; PONV coverage requires prior failure of a 5-HT3 antagonist at maximally indicated doses unless contraindicated.
covered

Line of Therapy

first-line

First-line: Used for prophylaxis with initial and repeat courses of moderately to highly emetogenic chemotherapy; continuation permitted while chemotherapy continues and member is responding.

informational

Informational: Use of NK1 agents is determined by chemotherapy emetogenicity rather than line number; recommended for MEC and HEC per guidelines.

Examples and guidance provided.

Coding

HCPCS Codes referencedHCPCS

J1453	Injection, fosaprepitant, 1 mg
J1456	Injection, fosaprepitant (Teva), not therapeutically equivalent to J1453, 1 mg
J0185	Injection, aprepitant, 1 mg
J8501	Aprepitant, oral, 5 mg
J8502	Injection, aprepitant (aponvie), 1 mg
J1434	Injection, fosaprepitant (Focinvez), 1 mg

Previously used / unclassifiedHCPCS

J3490

Unclassified drugs (previously referenced; later removed)

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests for aprepitant, fosaprepitant, Emend (oral suspension or capsules), Emend for injection, Focinvez, Cinvanti, Aponvie, and branded products must include documentation that the member meets indication, age, chemotherapy emetogenicity, and concomitant antiemetic regimen criteria in the policy.

Prior authorization applies to specialty HCPCS-coded agents (see Coding Implications).

Documentation Required

Documentation Required — Failure to Provide May Result in Denial

Providers must submit supporting clinical documentation (e.g., office chart notes, lab results, medication administration records) that the member meets all applicable approval criteria. Lack of sufficient documentation or requests for non‑FDA indications not covered by this policy may result in denial.

Include documentation of diagnosis, chemotherapy emetogenicity (see Appendix D), age, prior therapies, and rationale for brand use if applicable.

Definitions

HEC / MEC — Definitions and examples; guideline references

HECHighly emetogenic cancer chemotherapy (HEC) — chemotherapy regimens with high risk of nausea/vomiting; examples in Appendix D include cisplatin, carmustine, cyclophosphamide >1500 mg/m2, dacarbazine, mechlorethamine, streptozocin, fam‑trastuzumab deruxtecan‑nxki.

MECModerately emetogenic cancer chemotherapy (MEC) — chemotherapy regimens with moderate risk of nausea/vomiting; examples in Appendix D include carboplatin, irinotecan, oxaliplatin, cyclophosphamide ≤1500 mg/m2, cytarabine >200 mg/m2, daunorubicin, doxorubicin <60 mg/m2, epirubicin ≤90 mg/m2, bendamustine, clofarabine.

Guideline contextASCO and NCCN stratify prophylaxis by emetogenic risk and list recommended antiemetic combinations (see Appendix D); NK1 receptor antagonists are recommended for HEC and may be used for MEC in combination with a 5‑HT3 antagonist and dexamethasone.

Appendix referenceSee Appendix D for the policy’s examples of MEC and HEC agents and the ASCO/NCCN recommendations cited in the policy.

Background

Aprepitant and fosaprepitant are neurokinin‑1 (NK1) receptor antagonists indicated for use in combination with other antiemetics to prevent acute and delayed nausea and vomiting associated with moderately and highly emetogenic chemotherapy, and certain formulations are indicated for prevention of postoperative nausea and vomiting (PONV). Clinical guidance from ASCO and NCCN stratifies antiemetic prophylaxis by chemotherapy emetogenicity and recommends NK1 antagonists in combination with a 5‑HT3 receptor antagonist and dexamethasone for high emetic risk (HEC) and in selected moderately emetogenic (MEC) regimens.

Provider Quick Reference

Authorization & Documentation

Note

Prior authorization required

Note

Step therapy / brand-to-generic requirement

Note

Supporting documentation required

Note

Documentation and coding denial risks

Revision History

2026-03-31Appendix updateLatest

Appendix E updated to add Indiana to the list of states with step therapy/redirection prohibitions for cancer medications.

2026-02-18Coding update

HCPCS code J8502 was added and code C9145 was removed from the policy coding list.

2025-04-21Annual review - material changes

3Q 2025 annual review added Commercial line of business, added references to generics and age limits to the policy/criteria description, and added a step therapy bypass for Illinois HIM per IL HB 5395; Appendix E language and Tennessee exception were revised.

OpenPayer

Aprepitant and Fosaprepitant (NK1 receptor antagonists)

Coverage Criteria

Covered Regimens and Dosing

Line of Therapy

Coding

Provider Actions and Authorization Requirements

Definitions

Background

Provider Quick Reference

Revision History