CurrentNeighborhood Health Plan of Rhode IslandPolicy UM ONC_1468

Antiemetics

Defines accepted indications, continuation and exclusion criteria, dose limits, coding, and utilization management authority for antiemetic agents used in cancer-related chemotherapy and radiation-induced nausea/vomiting. Applies to medication requests processed by Evolent/Neighborhood Health Plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAntiemetics

Policy CodePolicy UM ONC_1468

Change TypeNo material changes

Effective DateJan 31, 2025

Next Review Date

Key ActionObtain Evolent authorization for antiemetic medications; off-label uses must be supported by FDA labeling, CMS-recognized compendia, NCCN/ASCO guidelines, or peer-reviewed literature meeting CMS standards.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes to this policy at this update.

13+Antiemetic agents listed

MultipleBilling codes provided

ListedDose maxima enumerated

Coverage Summary

Coverage stance: covered_with_criteria. Scope: defines accepted indications, continuation and exclusion criteria, dose limits, coding, and utilization management authority for antiemetic agents used in cancer-related chemotherapy and radiation-induced nausea/vomiting and applies to medication requests processed by Evolent/Neighborhood Health Plan. Subject: Antiemetics (ondansetron, granisetron, palonosetron, netupitant/netupitant combinations, aprepitant/fosaprepitant, rolapitant, granisetron patch/extended release). Payer processing responsibility: Evolent is responsible for processing all medication requests; medications not authorized by Evolent may be deemed not approvable and not reimbursable. Effective date: 2025-01-31. Last review date: 2025-01-08.

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Single-dose maximum thresholds (not covered if exceeded)

Ondansetron (IV) single-dose max16 mg

Ondansetron (PO) single-dose max24 mg

Granisetron single-dose max (IV/PO)2 mg

Sancuso (granisetron patch) single-dose3.1 mg patch

Aloxi (palonosetron) single-dose max IV0.25 mg

Aloxi (palonosetron) single-dose max PO0.5 mg

Akynzeo single-dose max (oral / IV)300 mg / 0.5 mg (oral) or 235 mg / 0.25 mg (IV)

Sustol (granisetron ER) single-dose max10 mg

Aprepitant single-dose max (oral)125 mg

Fosaprepitant single-dose max (injection)150 mg

Aprepitant (injection) single-dose max130 mg

Rolapitant single-dose max (oral)180 mg

Initial Therapy & Prophylaxis Criteria

Prophylaxis and treatment for chemotherapy- or radiation-induced nausea/vomiting

Antiemetics may be used as prophylaxis prior to administration of low, moderate, or high emetogenic risk chemotherapy and for radiation-induced nausea/vomiting when the following product-specific rules apply:

Serotonin (5-HT3) antagonists for prophylaxis

Zofran (ondansetron) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy
Kytril (granisetron) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy
Aloxi (palonosetron) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy
Sustol (granisetron extended release) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy
Akynzeo (netupitant oral / fosnetupitant injection - palonosetron) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy
Sancuso (granisetron patch) may be used as prophylaxis prior to low, moderate, or high emetogenic risk chemotherapy

Restriction for use of serotonin antagonists

Only Zofran (ondansetron) or Kytril (granisetron) can be used [see exclusion criteria for other antiemetics]
Use prior to radiation to the upper abdomen or total body irradiation OR for treatment of nausea/vomiting induced by radiation or anticancer therapy

NK1 receptor antagonist combinations for chemotherapy

Emend (fosaprepitant injection or aprepitant oral), Cinvanti (aprepitant injection), or Varubi (rolapitant oral) should be used in combination with dexamethasone and one of the following 5-HT3 antagonists: Zofran (ondansetron) or Kytril (granisetron) or Aloxi (palonosetron) for administration of low, moderate, or high emetogenic risk chemotherapy

Agents acceptable for radiation-induced or breakthrough nausea/vomiting

Aloxi (palonosetron) for prevention or treatment of radiation or total body irradiation induced nausea and vomiting or for treatment of breakthrough nausea/vomiting
Akynzeo (netupitant oral / fosnetupitant injection - palonosetron) for prevention or treatment of radiation induced nausea/vomiting or for breakthrough
Sancuso (granisetron patch) for prevention or treatment of radiation induced nausea/vomiting or for breakthrough
Sustol (granisetron extended release) for prevention or treatment of radiation induced nausea/vomiting or for breakthrough
Emend (fosaprepitant injection/oral aprepitant) for prevention or treatment of radiation induced nausea/vomiting or for breakthrough

Continuation Therapy Criteria

Continuation requests exemption

Continuation requests for a not-approvable medication shall be exempt from this Evolent policy provided:

ALL of the following

The member has not experienced disease progression on the requested medication
The requested medication was used within the last year without a lapse of more than 30 days of having an active authorization
Additional medication(s) are not being added to the continuation request

Prior Authorization

Continuation request exemption requirements

Continuation requests for a previously not-approvable medication may be exempt from this Evolent policy when the provider documents all three required conditions below. Exemption requests will be evaluated against these criteria when processing continuation/renewal requests.

The member has not experienced disease progression on the requested medication
The requested medication was used within the last year without a lapse of more than 30 days of having an active authorization
Additional medication(s) are not being added to the continuation request

Dose & Single-Dose Maximum Limits

Dose and single-dose maximum limits (Not covered if exceeded)

Use is not covered when dosing exceeds the specified single-dose maximum limits:

ALL of the following

Ondansetron IV single-dose limit: IV ondansetron (Zofran) single dose limit: 16 mgOndansetron IV single-dose limit: 16 mg
Ondansetron PO single-dose limit: Oral ondansetron (Zofran) single dose limit: 24 mgOndansetron PO single-dose limit: 24 mg
Granisetron single-dose limit: Granisetron single dose limit: 2 mg IV/POGranisetron single-dose limit: 2 mg IV/PO
Sancuso patch single-dose limit: Sancuso patch single dose limit: 3.1 mg patchSancuso patch single-dose limit: 3.1 mg patch
Anzemet single-dose limit: Anzemet single dose limit: 100 mgAnzemet single-dose limit: 100 mg
Aloxi IV single-dose limit: Aloxi single dose limit: 0.25 mg IVAloxi IV single-dose limit: 0.25 mg IV
Aloxi PO single-dose limit: Aloxi single dose limit: 0.5 mg POAloxi PO single-dose limit: 0.5 mg PO
Akynzeo single-dose limit: Akynzeo single dose limit: 300 mg/0.5 mg (oral) or 235 mg/0.25 mg (IV)Akynzeo single-dose limit: 300 mg/0.5 mg (oral) or 235 mg/0.25 mg (IV)
Sustol single-dose limit: Sustol single dose limit: 10 mgSustol single-dose limit: 10 mg
Aprepitant oral single-dose limit: Aprepitant oral single dose limit: 125 mgAprepitant oral single-dose limit: 125 mg
Fosaprepitant single-dose limit: Fosaprepitant injection single dose limit: 150 mgFosaprepitant single-dose limit: 150 mg
Rolapitant single-dose limit: Rolapitant oral single dose limit: 180 mgRolapitant single-dose limit: 180 mg
Aprepitant injection single-dose limit: Aprepitant injection single dose limit: 130 mgAprepitant injection single-dose limit: 130 mg

Denial Risk

Requests exceed single-dose maximums

Claims or prior authorization requests that exceed the policy’s specified single-dose maximum limits for the listed agents are not approvable and may be denied.

Ondansetron (IV single dose limit 16 mg; PO single dose limit 24 mg)
Granisetron (single dose limit 2 mg IV/PO)
Palonosetron (Aloxi) (single dose limit 0.25 mg IV; 0.5 mg PO)
Akynzeo (netupitant/palonosetron) (300 mg/0.5 mg oral or 235 mg/0.25 mg IV)
Aprepitant/fosaprepitant and rolapitant (individual single-dose limits listed in policy)

Investigational / Not Accepted Off-Label Uses

Investigational / Not accepted off-label uses

Use is investigational or not approvable when off-label indication lacks sufficient evidence as defined below:

ALL of the following

Clinical characteristics of the patient and the cancer are not adequately represented in the published evidence
The administered chemotherapy/biologic/immune/targeted/other oncologic therapy regimen is not adequately represented in the published evidence
Reported study outcomes do not represent clinically meaningful outcomes (ASCO guidance e.g., HR <0.80 or survival benefit for OS/PFS at least 3 months)
Experimental design is inappropriate to address the investigative question
Non-randomized clinical trials with insufficient subject numbers are relied upon without supportive evidence
Case reports or anecdotal uncontrolled data are the only evidence
Abstracts without a full peer-reviewed article are the only evidence

Documentation Required

Support off-label use with accepted evidence

Off‑label uses must be supported by one of the accepted evidence sources: FDA‑approved product labeling; a CMS‑recognized compendium; guideline recommendations from NCCN or ASCO; or peer‑reviewed literature that meets the CMS Medicare Benefit Policy Manual Chapter 15 standards (including adequate patient/ regimen representation and clinically meaningful outcomes per ASCO guidance).

FDA‑approved product labeling
CMS‑recognized compendia
NCCN or ASCO clinical guidelines
Peer‑reviewed literature meeting CMS Medicare Benefit Manual Chapter 15 standards (adequate populations/regimens and clinically meaningful outcomes)

Applicable Codes

HCPCS / J-codes and Q-codes listedmixedCovered

J2405	Injection, ondansetron hydrochloride, per mg
Q0162	Ondansetron 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	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, mg (for circumstances under the Medicare statute, use Q0166)
J2468	Injection, palonosetron hydrochloride, 25 micrograms
J2469	Injection, palonosetron HCl, 25 mcg

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Provider Actions & Operational Notes

Prior Authorization

Medications require authorization by Evolent

Evolent is responsible for processing all medication requests. Medications that are not authorized by Evolent may be deemed not approvable and therefore not reimbursable.

Documentation Required

Support off-label use with accepted evidence

Off‑label uses must be supported by FDA labeling, CMS‑recognized compendia, NCCN or ASCO guidance, or peer‑reviewed literature that meets CMS Chapter 15 standards. This requirement is reiterated here for operational visibility when documenting requests.

FDA‑approved product labeling
CMS‑recognized compendia
NCCN or ASCO clinical guidelines
Peer‑reviewed literature meeting CMS Chapter 15 standards

Denial Risk

Requests exceed single-dose maximums

Requests or claims that exceed the policy’s enumerated single‑dose maximums for the listed agents are not approvable and may be denied; providers should ensure dosing does not exceed the policy limits when submitting requests.

IV ondansetron single-dose limit: 16 mg
Oral ondansetron single-dose limit: 24 mg
Granisetron single-dose limit: 2 mg IV/PO
Sancuso patch single-dose limit: 3.1 mg patch
Aloxi single-dose limits: 0.25 mg IV / 0.5 mg PO
Akynzeo single-dose limits: 300 mg/0.5 mg (oral) or 235 mg/0.25 mg (IV)
Sustol single-dose limit: 10 mg
Aprepitant oral single-dose limit: 125 mg; fosaprepitant injection: 150 mg; rolapitant oral: 180 mg; aprepitant injection: 130 mg

Prior Authorization

Continuation request exemption requirements

To qualify for the continuation exemption for a previously not‑approvable medication, providers must document that the member has not had disease progression on the medication, that the medication was used within the last year without a lapse of more than 30 days of active authorization, and that no additional medications are being added to the continuation request.

No disease progression on the requested medication
Used within the last year without a >30‑day lapse of active authorization
No additional medication(s) added to the continuation request

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAntiemetics

Policy CodePolicy UM ONC_1468

Change TypeNo material changes

Effective DateJan 31, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

Antiemetics

Coverage Summary

Initial Therapy & Prophylaxis Criteria

Continuation Therapy Criteria

Dose & Single-Dose Maximum Limits

Investigational / Not Accepted Off-Label Uses

Applicable Codes

Provider Actions & Operational Notes

Clinical Evidence & Definitions

Revision History