CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Antiemetics for chemotherapy- and radiation-induced nausea and vomiting — Coverage Criteria

Defines accepted indications, exclusions, dosing limits, coding, and prior authorization expectations for antiemetic medications used for prevention and treatment of nausea/vomiting in oncology patients for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAntiemetics for chemotherapy- and radiation-induced nausea and vomiting — Coverage Criteria

Policy CodePolicy N/A

Change TypeUpdated exclusionsadded coding sectiontemplate conversion

Effective DateN/A

Next Review DateN/A

Key ActionSubmit medication requests to Evolent with supporting evidence from FDA labeling, CMS-recognized compendia, NCCN/ASCO guidelines, or acceptable peer-reviewed literature.

SourceLink

POLICY UPDATE CHANGES

Converted to new Evolent guideline template and replaced UM ONC_1468 Antiemetics.

Updated exclusion criteria.

Added coding information section with HCPCS and J-codes.

>=15-HT3 requirement with NK1

16/24Zofran single-dose max

150Fosaprepitant single-dose max

Commercial/Exchange/Medicaid

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Coverage Criteria

Initial and Continuation Coverage Criteria

Covered when ALL of the following are met:

General coverage prerequisites

Continuation criteria: Member has not experienced disease progression on the requested medication AND requested medication was used within the last year without a lapse >30 days AND no additional medications are being added to the continuation request.
Continuation requests exempt from policy if these are met

Combo therapy for NK1 agents: When using aprepitant, fosaprepitant, rolapitant, or netupitant, therapy must be given in combination with dexamethasone and one 5-HT3 antagonist (ondansetron, granisetron, or palonosetron).

Explicit requirement in policy

The following agents are addressed explicitly in this policy: Aloxi (palonosetron), Akynzeo (netupitant oral / fosnetupitant‑palonosetron), Sancuso (granisetron patch), Sustol (granisetron extended‑release), Emend (oral aprepitant / fosaprepitant injection), Cinvanti (aprepitant injection), and Varubi (rolapitant oral). These agents are included for prevention and treatment of chemotherapy‑induced nausea and vomiting when used according to the coverage criteria and documentation requirements in this policy.

Excluded uses include when Aloxi, Akynzeo, Sancuso, Sustol, Emend, Cinvanti, or Varubi are being used for the prevention or treatment of radiation‑induced or total body irradiation (TBI)‑induced nausea and vomiting, or for treatment of breakthrough nausea/vomiting (not prophylaxis).

Use of Emend, Cinvanti, or Varubi without a 5‑HT3 antagonist and dexamethasone is excluded. Dosing that exceeds the specified single‑dose maximums (see coding/thresholds) is excluded. Investigational or off‑label indications that lack sufficient supporting evidence—such as cases where patient/cancer characteristics or the administered oncologic regimen are not adequately represented in the published evidence, outcomes are not clinically meaningful per accepted standards, or evidence relies on case reports or abstracts without full peer‑reviewed articles—are considered not medically necessary and therefore excluded.

Regimen	Required components	Coverage status
5-HT3 antagonist alone for prophylaxis (ondansetron, granisetron, palonosetron, sustained-release granisetron, granisetron patch)	Per emetogenic risk, single-agent 5-HT3 antagonist prior to chemotherapy	Covered
NK1 agent-based regimen (aprepitant, fosaprepitant, rolapitant, netupitant-containing products)	Must be given in combination with dexamethasone AND a 5-HT3 antagonist (ondansetron, granisetron, or palonosetron)	Covered with criteria

Coding and Dose Limits

Antiemetic HCPCS/J codesmixed

J2405	Injection, ondansetron hydrochloride, per 1 mg
Q0162	Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen
S0119	Ondansetron, oral, 4 mg (for circumstances falling under the medicare statute, use hcpcs q code)
J1626	Injection, granisetron hydrochloride, 100 mcg
J1627	Injection, granisetron, extended-release, 0.1 mg
J3490	granisetron transdermal patch (3.1 mg/24 hours)
Q0166	Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen
S0091	Granisetron hydrochloride, 1 mg (for circumstances falling under the medicare statute, use q0166)
J2468	Injection, palonosetron hydrochloride (posfrea), 25 micrograms
J2469	Injection, palonosetron hcl, 25 mcg

1–10 of 20

1/2

Single-dose maximums — selected antiemetics

Ondansetron (Zofran)Maximum single dose: 16 mg IV or 24 mg PO.

Granisetron (Kytril/Sustol)Maximum single dose: 2 mg IV/PO; Sustol (extended-release) single-dose limit: 10 mg.

Granisetron transdermal (Sancuso)Patch single-dose: 3.1 mg.

Palonosetron (Aloxi)Maximum single dose: 0.25 mg IV or 0.5 mg PO.

Akynzeo (netupitant/palonosetron or fosnetupitant/palonosetron)Maximum single dose: oral 300 mg netupitant/0.5 mg palonosetron OR IV 235 mg fosnetupitant/0.25 mg palonosetron.

NK1 agents (Aprepitant/Fosaprepitant/Rolapitant)Maximum single doses: aprepitant oral 125 mg; fosaprepitant IV 150 mg; rolapitant oral 180 mg; aprepitant injection 130 mg.

Provider Actions and Authorization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for all medication requests processed by Evolent on behalf of Neighborhood Health Plan of Rhode Island. Medication use must be supported by FDA-approved labeling, CMS-recognized compendia, NCCN or ASCO clinical guidelines, or peer-reviewed literature that meets CMS guidance.

Evolent processes all medication requests for network ordering providers
Supporting evidence: FDA labeling, CMS compendia, NCCN, ASCO, or acceptable peer-reviewed literature

Note

Combination Therapy Requirement

Emend (fosaprepitant/aprepitant), Cinvanti (aprepitant injection), and Varubi (rolapitant) must be prescribed in combination with dexamethasone AND a 5-HT3 antagonist (e.g., ondansetron, granisetron, or palonosetron) when used as prophylaxis prior to administration of emetogenic chemotherapy.

Required combination: NK1 agent + dexamethasone + 5-HT3 antagonist (ondansetron, granisetron, or palonosetron)

Definitions and Drug Classes

5-HT3 receptor antagonists — examples and formulations

Ondansetron (Zofran)5-HT3 receptor antagonist available as IV and PO formulations; listed for prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy.

Granisetron (Kytril/Sustol)5-HT3 receptor antagonist available IV and PO; Sustol is an extended‑release formulation; Sancuso is a transdermal granisetron patch.

Palonosetron (Aloxi)Second‑generation 5‑HT3 antagonist available IV and PO formulations; indicated for CINV prophylaxis.

FormulationsClass formulations include IV, PO (oral), extended‑release injectable, and transdermal patch options for different clinical settings.

NK1 receptor antagonists — class examples and combination use notes

Aprepitant (Emend/Cinvanti)

Applicable Lines of Therapy

Line of Therapy Applicability

Prophylaxis across emetogenic risk: Zofran (ondansetron), Kytril (granisetron), Aloxi (palonosetron), Sustol (granisetron extended release), Akynzeo (netupitant oral/fosnetupitant injection + palonosetron), and Sancuso (granisetron patch) may be used as prophylaxis prior to administration of low, moderate, or high emetogenic risk chemotherapy.

Agents listed for prophylaxis across emetogenic risk levels.

Background

Antiemetic therapy for oncology patients includes two principal classes addressed in this policy: 5‑HT3 receptor antagonists (e.g., ondansetron, granisetron, palonosetron, including IV, PO, extended‑release, and transdermal formulations) and NK1 receptor antagonists (e.g., aprepitant, fosaprepitant, netupitant, rolapitant). For prevention of chemotherapy‑induced nausea and vomiting, combination regimens of an NK1 agent + a 5‑HT3 antagonist + dexamethasone are required when an NK1 agent is used; monotherapy with a 5‑HT3 antagonist may be appropriate for prophylaxis based on the emetogenic risk of the chemotherapy. Continuation use is allowed under the policy’s continuity criteria when supported by appropriate evidence sources.