CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

aprepitant_non_oncology_indications

Defines coverage for aprepitant 40 mg capsules for prevention of postoperative nausea and vomiting (PONV) in adults within the Medicaid scope when approval criteria are met; all other indications are considered experimental/investigational and not covered.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyaprepitant_non_oncology_indications

Policy CodePolicy N/A

Change Typeclarified

Effective DateDec 1, 2017

Next Review Date

Key ActionPrior authorization for up to 1 month may be granted when aprepitant 40 mg capsules are prescribed for prevention of postoperative nausea and vomiting in adults and the member has no exclusions to therapy.

POLICY UPDATE CHANGES

Policy lists FDA-approved and compendial use for prevention of PONV with aprepitant 40 mg capsules as a covered benefit when approval criteria are met.

1Covered Indication (Non-oncology)

1 monthAuthorization Duration

multipleReviewed Dates

Coverage Summary

Defines coverage for aprepitant 40 mg capsules for the prevention of postoperative nausea and vomiting (PONV) in adults within the Medicaid scope when approval criteria are met. Authorization may be granted for this non-oncology indication when the specified criteria are satisfied. All other indications are considered experimental/investigational and are not a covered benefit. (Effective: 12/2017; Last review: 05/2024.)

Key Policy Facts

Covered Indication (Non-oncology)Prevention of postoperative nausea and vomiting (PONV) in adults — covered when approval criteria are met

Authorization DurationUp to 1 month may be granted for PONV

Reviewed DatesMultiple review dates listed (Reviewed: 12/2017, 12/2018, 5/2019, 2/2020, 5/2021, 4/2022, 4/2023, 4/2024, 5/2024)

Policy StatusCURRENT

Policy SubjectAprepitant 40 mg capsules for non-oncology indications (PONV)

Initial Therapy Criteria (Authorization)

Authorization Criteria (Non-Oncology Indications)

Authorization of 1 month may be granted when ALL of the following criteria are met:

ALL of the following

Aprepitant 40 mg capsules are being prescribed for the prevention of postoperative nausea and vomiting (PONV) in an adult.
Member has no exclusions to the prescribed therapy.

Limitations of Use and Not Covered

Limitations of Use / Not Covered

The following are limitations or not covered:

ANY of the following

Aprepitant has not been studied for the treatment of established nausea and vomiting.
Chronic continuous administration of aprepitant is not recommended and is not covered because it has not been studied and drug interaction profile may change during chronic continuous use.
All other indications besides PONV (FDA-approved indications and compendial uses not listed above) are considered experimental/investigational and are not a covered benefit.

Authorization for PONV is limited to 1 month; chronic continuous administration is not recommended or covered. Chronic use is specifically disallowed because it has not been studied and the drug interaction profile may change during chronic continuous use. All other indications besides PONV remain experimental/investigational and are not covered.

Provider Actions

Prior Authorization

Authorization required for non-oncology aprepitant

Prior authorization for up to 1 month may be granted when aprepitant 40 mg capsules are prescribed for prevention of PONV in adults and the member has no exclusions to therapy.

Documentation Required

Document PONV indication

Prescribers should document that aprepitant 40 mg is being used for prevention of postoperative nausea and vomiting and that the member has no therapy exclusions to support prior authorization and claims adjudication.

Revision History

2017-12-01effective

Policy lists FDA-approved and compendial use for prevention of PONV with aprepitant 40 mg capsules as a covered benefit when approval criteria are met.

2017-12-01authorization_limit

Authorization limited to 1 month for prevention of postoperative nausea and vomiting (PONV) when specified criteria are met.

2017-12-01coverage_restriction

Chronic continuous administration of aprepitant is not recommended and is not covered; aprepitant has not been studied for treatment of established nausea and vomiting.

2024-05-01last_reviewLatest

Policy reaffirmed: aprepitant 40 mg capsules indicated for prevention of PONV in adults as a covered benefit when approval criteria are met; all other indications are considered experimental/investigational and not covered.