CurrentmhnPolicy CP.PMN.19

Aprepitant and Fosaprepitant (NK1 receptor antagonists) — Medical necessity and prior authorization criteria

Medical necessity and prior authorization criteria for aprepitant (Aponvie, Emend, Cinvanti) and fosaprepitant (Emend for Injection, Focinvez) for prevention of chemotherapy- and postoperative-associated nausea and vomiting for applicable Centene lines of business.

Policy Summary

Payermhn

PolicyAprepitant and Fosaprepitant (NK1 receptor antagonists) — Medical necessity and prior authorization criteria

Policy CodePolicy CP.PMN.19

Change TypeAnnual review — no material changes

Effective DateNov 1, 2006

Next Review Date

Key ActionSubmit prior authorization with documentation of indication, age, emetogenicity of chemotherapy, concomitant antiemetics, and dosing consistent with policy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Dose limitsexplicit dosing caps per regimen

18+minimum age for PONV

pimozidecontraindication listed

6 codesHCPCS/J codes referenced

Coverage Criteria for Aprepitant and Fosaprepitant

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Initial Therapy - Chemotherapy-associated CINV

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

CINV Initial: 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 preferred) and dexamethasone; 6) If request is for brand Emend, Focinvez, or Cinvanti, one of the following applies: (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- and age-specific limits (see dosing node).

See dosing subnode for exact dose limits.

CINV Dosing: Emend oral suspension/capsules: Day 1 125 mg then Days 2–3 80 mg per cycle; if age ≥ 6 months and < 12 years: Day 1 3 mg/kg then Days 2–3 2 mg/kg. Emend for injection/Focinvez single-dose: Day 1 150 mg (if age 2 to <12 years: 4 mg/kg; if age 6 months to <2 years: 5 mg/kg). Emend for injection/Focinvez 3-day regimen: Day 1 115 mg (if age 6 months to <12 years: 3 mg/kg Day 1). Cinvanti: single-dose Day 1 130 mg for HEC and MEC, or 3-day regimen Day 1 100 mg for MEC.dose caps per product and age

Exact product- and age-specific dosing per policy dosing tables.

Initial Therapy - Postoperative Nausea and Vomiting

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

PONV Initial: 1) Request is for generic aprepitant capsules or Aponvie; 2) Prescribed for the prevention of postoperative nausea and vomiting (PONV); 3) Age ≥ 18 years; 4) Member is scheduled to receive surgery; 5) Failure of a 5-HT3 receptor antagonist (ondansetron preferred) at up to maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced (Illinois HIM exception: step therapy requirements do not apply for formulary agents as of 1/1/2026); 6) Dose does not exceed one of the following: generic aprepitant capsules 40 mg once OR Aponvie 32 mg once.age >=18; prior failure of 5-HT3 at max doses

Step therapy exceptions per state-specific rules (see Appendix E and IL HB 5395).

Continuation Therapy - Chemotherapy-associated CINV

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

CINV Continued: 1) Member meets one of the following: (a) currently receiving medication via Centene benefit or previously met initial approval criteria, or (b) member is currently 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 preferred) and dexamethasone; 5) If request is for brand Emend, Focinvez, or Cinvanti, one of the following applies: (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, the new dose does not exceed product- and age-specific limits (same caps as initial dosing).

Approval duration: projected duration of chemotherapy.

Medical necessity for aprepitant/fosaprepitant

Covered when dosing and indication align with FDA-approved uses and guideline-based emetogenic risk recommendations

Primary coverage criteria: 1) Indication is prevention of chemotherapy-induced nausea and vomiting (CINV) or prevention of postoperative nausea and vomiting (PONV) as specified for each product; 2) Dosing follows product-specific regimens (examples: Emend capsules 125 mg PO Day 1 then 80 mg PO Days 2–3; Emend for injection/fosaprepitant single-dose 150 mg IV Day 1 for adults; Aponvie 32 mg IV prior to induction for PONV; Cinvanti single-dose 130 mg IV Day 1 for HEC/MEC; see dosing tables for full age-specific regimens); 3) For CINV, use is aligned with emetogenic risk: NK1 antagonists are recommended for HEC and recommended or considered for MEC in combination with 5-HT3 antagonist and dexamethasone per NCCN/ASCO guidance; 4) Pediatric dosing as specified for age groups must be used when applicable.

Exact regimen and age-specific doses are specified in policy dosing tables (V. Dosage and Administration).

Non‑FDA approved indications that are not specifically addressed in this policy are excluded from coverage unless the provider submits sufficient documentation of efficacy and safety consistent with applicable off‑label use policies (e.g., CP.CPA.09 for commercial, HIM.PA.154 for marketplace, CP.PMN.53 for Medicaid) or other evidence of coverage documents that justify the off‑label use.

Aprepitant and fosaprepitant are contraindicated in patients with a known hypersensitivity to the agent and with concurrent use of pimozide. No boxed warnings are reported for these agents in this policy.

These products have not been studied for the management of established nausea and vomiting; use for treatment of established symptoms is therefore not supported by this policy. In addition, chronic continuous administration of Emend oral suspension or capsules is not recommended.

NK1 receptor antagonists are not routinely recommended for chemotherapy regimens with minimal or low emetic risk. For low risk chemotherapy, recommended antiemetic options per ASCO/NCCN include dexamethasone, metoclopramide, prochlorperazine, or a 5‑HT3 receptor antagonist (NCCN), and NK1 antagonists are not included in those low‑risk recommendations.