CurrentPremera BluecrossPolicy 5.01.662

Antiemetic Medications

Defines medical necessity criteria and authorization parameters for specified antiemetic drugs under the pharmacy benefit for Premera members, including cancer-, motion sickness-, and pregnancy-related indications.

Policy Summary

PayerPremera Bluecross

PolicyAntiemetic Medications

Policy CodePolicy 5.01.662

Change TypeNew policymaterial revisions and additions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization through the pharmacy benefit and document prior trials and medical records showing criteria are met.

SourceLink

POLICY UPDATE CHANGES

New policy created and approved March 10, 2026; moved coverage criteria from policy 5.01.605 into this new policy and added Nereus (tradipitant) criteria.

Updated Bonjesta and Diclegis criteria to require trial and inadequate response or intolerance to OTC pyridoxine plus OTC doxylamine; added coverage for generic doxylamine and pyridoxine delayed-release.

Added quantity limits for Akynzeo (1 capsule per fill) and Sancuso (1 transdermal system per fill).

Added coverage criteria for Nereus (tradipitant) for vomiting induced by motion sickness including prior therapy requirements and dosing limits.

~10products addressed

12 moapproval length

1Akynzeo limit

1Sancuso limit

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Coverage Criteria for Antiemetic Medications

Akynzeo (adults)

Cancer-related antiemetics covered when ALL of the following are met

Akynzeo (netupitant and palonosetron) - adults: Member is >=18 years AND has moderate-to-high emetic risk AND medication is being used in combination with dexamethasone and a serotonin receptor antagonist (e.g., ondansetron) AND quantity is limited to 1 capsule per fill

oral use only

Varubi (adults)

Cancer-related antiemetics covered when ALL of the following are met

Varubi (rolapitant) - adults: Member is >=18 years AND has moderate-to-high emetic risk AND medication is being used in combination with dexamethasone and a serotonin receptor antagonist (e.g., ondansetron)

Emend (aprepitant)

Emend (aprepitant) coverage varies by age and indication

Emend (aprepitant) oral - chemotherapy, age >=12: Member is >=12 years AND has moderate-to-high emetic risk AND medication is being used in combination with dexamethasone and a serotonin receptor antagonist (e.g., ondansetron) AND has tried generic aprepitant and had an inadequate response or intolerance

Quantity limited to two 80 mg capsules per fill OR one TriPack (one 125 mg + two 80 mg)

Emend (aprepitant) oral - chemotherapy, age <=11: Member is <=11 years AND has moderate-to-high emetic risk AND medication is being used in combination with a serotonin receptor antagonist (e.g., ondansetron)

Quantity limited to two 80 mg capsules per fill OR one TriPack (one 125 mg + two 80 mg)

Emend (aprepitant) oral - post-operative nausea and vomiting (adults): Member is >=18 years AND has tried generic aprepitant and had an inadequate response or intolerance to generic aprepitant

Quantity limited to two 80 mg capsules per fill

Sancuso (adult)

Sancuso (granisetron transdermal system) criteria

Sancuso - adults: Member is >=18 years AND has moderate-to-high emetic risk

Quantity limited to 1 transdermal system per fill

Syndros (dronabinol)

Syndros (dronabinol oral solution) coverage when ALL are met

Syndros - adults: Member is >=18 years AND requires treatment for (a) nausea and vomiting associated with cancer chemotherapy with failure of conventional antiemetic treatments OR (b) anorexia associated with weight loss in individuals with AIDS AND has tried and had an inadequate response or intolerance to generic dronabinol capsules OR documentation provided that oral solution is medically necessary (e.g., unable to swallow)

oral solution

Nereus (motion sickness)

Motion sickness-related antiemetic (Nereus) covered when ALL are met

Nereus (tradipitant) - adults: Member is >=18 years AND no evidence of another underlying condition causing chronic nausea AND has tried and had an inadequate response or intolerance to (a) two first-generation antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine) AND (b) scopolamine patch170 mg daily

Will not be used in combination with other anti-nausea/anti-emetic medications; quantity limited to 30 capsules per 15 days; initial approval 30 days

Pregnancy-related agents

Pregnancy-related antiemetics covered when ALL are met

Bonjesta / Diclegis: Member has nausea and vomiting of pregnancy AND has tried and had an inadequate response or intolerance to over-the-counter pyridoxine plus over-the-counter doxylamine AND has tried and had an inadequate response or intolerance to generic doxylamine and pyridoxine delayed-release

Bonjesta and Diclegis covered when prior therapy trials documented

Generic doxylamine and pyridoxine DR: Member has nausea and vomiting of pregnancy AND has tried and had an inadequate response or intolerance to over-the-counter pyridoxine plus over-the-counter doxylamine

All uses of the medications listed in this policy that are not explicitly described under the specified coverage criteria are considered investigational. Providers requesting coverage for indications, populations, or regimens not outlined in the policy should expect denial unless sufficient documentation demonstrates the request meets an exception supported by clinical evidence and medical necessity.

Coding and Dose Limits

Codingmixed

No codes listed

Nereus dosing and limits

Nereus (tradipitant) maximum daily doseDose is limited to 170 mg daily

Combination useWill not be used in combination with other anti-nausea or anti-emetic medications

Initial approval durationInitial approval will be for 30 days

Quantity limitQuantity limited to 30 capsules per 15 days

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial and re-authorization reviews for drugs listed in this policy may be approved for up to 12 months. Non-formulary exception reviews may also be approved for up to 12 months.

Initial authorization: up to 12 months
Re-authorization: up to 12 months (requires continued positive clinical response and meeting drug-specific criteria)

Denial Risk

Failure to Meet Drug-Specific Criteria May Lead to Denial

Coverage for specific agents requires meeting the drug-specific age, indication, combination-therapy, and quantity limits described in the policy (for example: Akynzeo—age ≥18, used with dexamethasone and a serotonin receptor antagonist, quantity limit 1 capsule per fill; Emend/aprepitant—age and quantity limits and, for some indications, trial of generic aprepitant). Failure to meet these drug-specific criteria may result in denial.

Background

Antiemetic agents are used to prevent or treat nausea and vomiting arising from a variety of causes, including chemotherapy, pregnancy, motion sickness, and other medical conditions. Multiple neurotransmitter systems (for example, 5-HT3, NK1, dopamine, histamine, acetylcholine, and cannabinoid receptors) mediate emesis, and combination regimens are commonly employed for individuals at moderate-to-high emetic risk. These agents therefore play a central role in supportive care for oncologic treatment and in symptom control for other clinical situations where nausea and vomiting impair patient safety or quality of life.

Definitions

Moderate-to-high emetic risk — key point

DefinitionModerate-to-high emetic risk: risk level of chemotherapy known to frequently cause nausea/vomiting; these patients commonly require combination antiemetic regimens

Clinical implicationIndividuals with moderate-to-high emetic risk should receive combination regimens (e.g., NK1 RA + dexamethasone + 5-HT3 RA)

Typical settingApplies to individuals receiving oncologic treatment with agents known to have moderate-to-high likelihood of inducing emesis

Initial Therapy Criteria

Initial therapy limits

Initial approval and limits

Nereus initial course: Initial approval for Nereus will be for 30 days; each additional treatment course will be evaluated as an initial authorization and the individual must meet the medical necessity criteria

Continuation and Re-authorization Criteria

Continuation therapy

Re-authorization

Re-authorization general: May be approved up to 12 months if drug-specific criteria are met and chart notes demonstrate continued positive clinical response to therapy

Non-formulary exception reviews follow same rules

Step Therapy Requirements

Requirement	Details
Prior trial documented	Documentation of prior trial and inadequate response or intolerance to the specified generic or OTC alternative(s) is required before coverage of brand products (e.g., generic aprepitant before Emend; OTC pyridoxine + OTC doxylamine then generic doxylamine/pyridoxine DR before Bonjesta/Diclegis).
Specific examples	Emend (aprepitant oral, select indications): has tried generic aprepitant and had an inadequate response or intolerance prior to coverage; quantity limited to two 80 mg capsules per fill or one TriPack per fill (one 125 mg + two 80 mg).
Pregnancy-related agents	Bonjesta and Diclegis require trial and inadequate response or intolerance to OTC pyridoxine plus OTC doxylamine and to generic doxylamine/pyridoxine delayed-release prior to coverage.
Motion sickness agent (Nereus)	Prior trial and inadequate response or intolerance required to two first-generation antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine) AND a scopolamine patch before coverage.
Documentation to submit	Medical records documenting prior therapy trials and evidence of inadequate response or intolerance must be provided as part of the authorization request.

Quantity Limits

Akynzeo (netupitant and palonosetron) — quantity limit

Akynzeo quantity limitQuantity is limited to 1 capsule per fill

IndicationPrevention of nausea and vomiting associated with oncologic treatment in adults

Combination requirementUsed in combination with dexamethasone and a serotonin receptor antagonist (e.g., ondansetron)

Emend (aprepitant) — allowable quantities

Allowed dispensing optionsTwo 80 mg capsules per fill OR one TriPack per fill (one 125 mg + two 80 mg)

Indication (age)Prevention of chemotherapy-associated nausea/vomiting: age >=12 years (varies by specific indication)

Site of Care

Note

Managed through the pharmacy benefit

This policy and authorizations are managed through the pharmacy benefit; medications covered under this policy are dispensed via the pharmacy benefit.