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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsPremera Bluecross Antiemetic Coverage Update | Ope…
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    ModifiedPremera BluecrossPolicy 5.01.662

    Antiemetic Medications

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    Pharmacy benefit policy describing medical necessity criteria, limits, and documentation for coverage of specific antiemetic drugs (oncology-, pregnancy-, motion sickness-, and post-operative–related) for Premera Bluecross members.

    Policy Summary
    PayerPremera Bluecross
    PolicyAntiemetic Medications
    Policy CodePolicy 5.01.662
    Change TypeMaterial updates and consolidationmultiple product additions and quantity-limit changes
    Effective DateAug 1, 2026
    Last ReviewJul 27, 2026
    Next Review DateJul 27, 2026
    Key ActionObtain prior authorization under the pharmacy benefit and document prior trials (including OTC pyridoxine + doxylamine where required) and quantity limits to meet medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    New policy created and coverage criteria moved from policy 5.01.605 into 5.01.662 and new criteria for Nereus (tradipitant) for motion-sickness vomiting were added.

    Akynzeo criteria updated with a quantity limit of 1 capsule per fill and Sancuso criteria updated with a quantity limit of 1 transdermal system per fill.

    Brand dronabinol solution added with the same criteria as Syndros (dronabinol oral solution).

    Bonjesta and Diclegis criteria updated to require prior inadequate response or intolerance to over-the-counter pyridoxine plus doxylamine; quantity limits updated for Bonjesta (60/30 days) and Diclegis/generic (120/30 days).

    Varubi (rolapitant) quantity limit added: 2 tablets per fill.

    Moved coverage criteria for multiple antiemetic products from policy 5.01.605 to policy 5.01.662 and added new and updated criteria and quantity limits for several products.

    Added new policy criteria for Nereus (tradipitant) for treatment of vomiting induced by motion sickness.

    Updated Bonjesta and Diclegis criteria to require prior trial and inadequate response or intolerance to over-the-counter pyridoxine plus doxylamine; added generic doxylamine/pyridoxine delayed-release coverage.

    Updated Akynzeo criteria and added a quantity limit of 1 capsule per fill.

    Updated Sancuso criteria and added a quantity limit of 1 transdermal system per fill.

    Added brand dronabinol solution to the policy with the same criteria as Syndros (dronabinol oral solution).

    Updated Varubi (rolapitant) criteria adding a quantity limit of 2 tablets per fill.

    Changed Nereus (tradipitant) quantity limit from 30 capsules per 15 days to 16 capsules per 30 days.

    Removed reference to non-formulary exception reviews.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12 monthsmax approval duration
    1Akynzeo qty/fill
    1Sancuso qty/fill
    60Bonjesta qty/30d
    120Diclegis/generic qty/30d
    8+products referenced

    Coverage and Medical Necessity Criteria

    Akynzeo (netupitant and palonosetron) — initial criteria

    Akynzeo (netupitant and palonosetron) — oncology-related

    Akynzeo (oral): The individual is aged 18 years or older 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 the quantity is limited to 1 capsule per fill.

    Emend (aprepitant)

    Emend (aprepitant) — oncology and post-operative

    Emend (oral aprepitant) for oncology: The individual is aged 12 years or older 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 and had an inadequate response or intolerance to generic aprepitant AND the quantity is limited to either two 80 mg capsules per fill OR one TriPack per fill (one 125 mg capsule + two 80 mg capsules).
    Emend for post-operative nausea and vomiting: The individual is aged 18 years or older AND has tried and had an inadequate response or intolerance to generic aprepitant AND the quantity is limited to either two 80 mg capsules per fill OR one TriPack per fill (one 125 mg capsule + two 80 mg capsules).

    Sancuso (granisetron transdermal system)

    Sancuso (granisetron transdermal system) — oncology-related

    Sancuso (transdermal): For prevention of nausea and vomiting associated with oncologic treatment when the individual is aged 18 years or older AND has moderate-to-high emetic risk AND medication is being used in combination with a serotonin receptor antagonist (e.g., ondansetron) AND the quantity is limited to 1 transdermal system per fill.

    Brand dronabinol solution and Syndros

    Dronabinol (brand solution and Syndros) — oncology and AIDS-related

    Brand dronabinol solution / Syndros: The individual is aged 18 years or older AND requires treatment for either (a) nausea and vomiting associated with cancer chemotherapy with inadequate response to conventional antiemetic treatments OR (b) anorexia with weight loss associated with AIDS AND has tried and had an inadequate response or intolerance to generic dronabinol capsules OR documentation is provided that the oral solution is medically necessary (e.g., unable to swallow solid dosage form).

    Varubi (rolapitant)

    Varubi (rolapitant) — oncology-related

    Varubi (rolapitant): The individual is aged 18 years or older 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 the quantity is limited to 2 tablets per fill.

    Nereus (tradipitant) for motion sickness–induced vomiting

    Nereus (tradipitant) — motion sickness

    Nereus (tradipitant): The individual is 18 years or older AND there is no evidence of another underlying condition causing chronic nausea AND has tried and had an inadequate response or intolerance to two first-generation antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine) AND scopolamine patch AND Nereus will not be used in combination with other anti-nausea or anti-emetic medications AND the dose is limited to 170 mg daily AND the quantity is limited to 16 capsules per 30 days. Initial approval is for 30 days; each additional course will be evaluated as an initial authorization and the individual must meet the same medical necessity criteria.

    Pregnancy-related agents

    Pregnancy-related antiemetics (Bonjesta, Diclegis, generic doxylamine/pyridoxine)

    Bonjesta (doxylamine/pyridoxine ER): The individual has tried and had an inadequate response or intolerance to over-the-counter pyridoxine in combination with over-the-counter doxylamine AND has tried and had an inadequate response or intolerance to generic doxylamine and pyridoxine delayed-release AND the quantity is limited to 60 tablets per 30 days.
    Diclegis (doxylamine/pyridoxine DR): The individual has tried and had an inadequate response or intolerance to over-the-counter pyridoxine in combination with over-the-counter doxylamine AND the quantity is limited to 120 tablets per 30 days.

    Policy text contains sections referencing 60 tablets; history clarifies Diclegis and generic limits updated to 120 tablets per 30 days.

    Generic doxylamine and pyridoxine delayed-release: The individual has tried and had an inadequate response or intolerance to over-the-counter pyridoxine in combination with over-the-counter doxylamine AND the quantity is limited to 120 tablets per 30 days.

    All other uses of the drugs listed in this policy that are not specifically described under the product-specific medical necessity criteria are considered investigational. Coverage is limited to the indications and conditions enumerated in this policy; requests for use outside those indications should be evaluated as investigational and will not meet the medical necessity criteria in this policy.

    This medical policy does not apply to Medicare Advantage. Member benefit language and coverage for Medicare Advantage plans may differ; providers should consult the member's benefit booklet or contact the plan's customer service for coverage specifics.

    Uses of the listed antiemetic drugs that fall outside the specific indications and coverage criteria set forth in this policy are considered investigational and therefore not medically necessary. Documentation supporting medical necessity must demonstrate that the requested use meets the product-specific criteria; absence of such documentation may result in denial.

    Initial Therapy Requirements

    Initial therapy specifics — 1 top-level node

    Initial therapy specifics

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

    Continuation and Re-authorization Criteria

    Continuation therapy — Re-authorization

    Re-authorization

    Re-authorization of all drugs listed (unless noted otherwise) may be approved up to 12 months if drug-specific coverage criteria are met and chart notes show continued positive clinical response to therapy.

    Step Therapy and Prior Trial Requirements

    RequirementDetails
    Documentation of prior trial and inadequate response/intolerance required
    Several agents require documentation that the member has tried and had an inadequate response or intolerance to specified generic or over-the-counter alternatives prior to coverage (examples include: generic aprepitant required before branded Emend; trial of generic doxylamine and pyridoxine delayed-release or OTC pyridoxine plus OTC doxylamine required prior to Bonjesta, Diclegis, or generic doxylamine/pyridoxine delayed‑release). Medical record must include office visit notes with diagnosis, relevant history, physical evaluation, and medication history documenting prior trials and reasons for inadequate response or intolerance.
    RequirementDetails
    Trial of OTC pyridoxine + doxylamine required before coverage
    Bonjesta, Diclegis, and generic doxylamine/pyridoxine delayed‑release require a prior trial of over‑the‑counter pyridoxine in combination with over‑the‑counter doxylamine with documentation of inadequate response or intolerance before the prescription products will be considered medically necessary. (Policy history and criteria updates specify this step-therapy requirement.)
    Prior Authorization

    Step therapy — required prior trials and specified alternatives

    Several products in this policy require documentation that the member tried and had an inadequate response or intolerance to specified generic or over‑the‑counter alternatives before coverage of the requested branded or product-specific agent will be approved.

    • Emend (aprepitant) — member must have tried and had an inadequate response or intolerance to generic aprepitant prior to approval; quantity limits apply (two 80 mg capsules per fill or one TriPack per fill).
    • Bonjesta and Diclegis (and generic doxylamine/pyridoxine delayed‑release) — member must have tried and had an inadequate response or intolerance to over‑the‑counter pyridoxine in combination with over‑the‑counter doxylamine prior to approval.
    • Nereus (tradipitant) — member must have tried and had an inadequate response or intolerance to two first‑generation antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine) and a scopolamine patch prior to approval.
    Step Therapy

    Quantity Limits by Product

    inv-27: Akynzeo (netupitant and palonosetron) — quantity limit
    Quantity limit1 capsule per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18, moderate-to-high emetic risk, and used with dexamethasone + a 5-HT3 antagonist
    Approval durationUp to 12 months if criteria met
    inv-28: Emend (aprepitant) — quantity limit (two 80 mg capsules OR one TriPack)
    Quantity limitTwo 80 mg capsules per fill OR one TriPack (one 125 mg + two 80 mg) per fill
    Age limitsOncology: aged ≥12; Post-operative: aged ≥18

    Provider Requirements, Authorization, and Documentation

    Prior Authorization

    Pharmacy benefit — prior authorization required

    This policy is managed under the pharmacy benefit and the prescription antiemetic drugs listed require prior authorization per the drug‑specific medical necessity criteria; initial approvals are generally up to 12 months unless otherwise noted.

    • Submit prior authorization requests through the pharmacy benefit process.
    • Initial authorizations generally approved up to 12 months when criteria are met.
    Prior Authorization

    Product‑specific prior authorization and quantity limits

    Prior authorization is required for the listed prescription antiemetic products and approvals are contingent on meeting the product‑specific medical necessity criteria and quantity limits moved into this policy from policy 5.01.605.

    • Ensure the member meets the specific age, prior‑trial, combination‑therapy, and quantity limit criteria for the requested product (see product criteria).
    • Requests that do not meet the product‑specific criteria and quantity limits may be denied.

    Coding

    Codingmixed
    No codes listed

    Background and Scope

    Nausea and vomiting arise from activation of the vomiting center through multiple afferent pathways and neurotransmitters, including 5-HT3 (serotonin) and NK1 receptors; these pathways are common targets of antiemetic therapy. Antiemetic agents in this policy act on those pathways and are intended for prevention and treatment of nausea and vomiting related to chemotherapy, postoperative states, pregnancy, motion sickness, and other specified causes when drug-specific criteria are met. Documentation of diagnosis, prior therapeutic trials, and response or intolerance to alternatives is required to establish medical necessity.

    Definitions and Risk Categories

    inv-21: moderate-to-high emetic risk — emetic risk categories
    DefinitionModerate-to-high emetic risk: emetic risk categories (used to determine need for specific antiemetic regimens)
    Clinical relevanceRequired as an eligibility criterion for several oncology-related antiemetics (e.g., Akynzeo, Varubi, Sancuso)
    Source contextEmetic risk categories relate to pathways and neurotransmitter receptors (5-HT3, NK1) involved in vomiting
    inv-22: Antiemesis definition
    DefinitionAntiemesis: prevention and treatment of nausea and vomiting.
    Clinical scopeApplies to agents used for chemotherapy-induced, postoperative, pregnancy-related, motion sickness–related, and other causes of nausea/vomiting

    Site of Care and Benefit Administration

    Note

    Site of care — pharmacy benefit / outpatient dispensing

    Antiemetic coverage under this policy is managed through the pharmacy benefit and applies to outpatient pharmacy dispensing for home use.

    • Dispense and bill these agents through the outpatient pharmacy channel; they are not managed as medical‑benefit outpatient infusions under this policy.

    Policy Revision History

    Policy Summary
    PayerPremera Bluecross
    PolicyAntiemetic Medications
    Policy CodePolicy 5.01.662
    Change TypeMaterial updates and consolidationmultiple product additions and quantity-limit changes
    Effective DateAug 1, 2026
    Last ReviewJul 27, 2026
    Next Review DateJul 27, 2026
    Key ActionObtain prior authorization under the pharmacy benefit and document prior trials (including OTC pyridoxine + doxylamine where required) and quantity limits to meet medical necessity.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaInitial Therapy RequirementsContinuation and Re-authorization CriteriaStep Therapy and Prior Trial RequirementsQuantity Limits by ProductProvider Requirements, Authorization, and DocumentationCodingBackground and ScopeDefinitions and Risk CategoriesSite of Care and Benefit AdministrationPolicy Revision History

    Step requirement — OTC pyridoxine + doxylamine trial required before Bonjesta/Diclegis

    For pregnancy‑related products (Bonjesta, Diclegis, generic doxylamine/pyridoxine delayed‑release), the policy requires a prior trial of over‑the‑counter pyridoxine plus over‑the‑counter doxylamine with inadequate response or intolerance documented before Bonjesta or Diclegis (and generics) will be considered medically necessary.

    • Bonjesta — requires documented trial and inadequate response or intolerance to OTC pyridoxine plus OTC doxylamine and to generic doxylamine/pyridoxine delayed‑release; quantity limited to 60 tablets per 30 days.
    • Diclegis and generic doxylamine/pyridoxine delayed‑release — require documented trial and inadequate response or intolerance to OTC pyridoxine plus OTC doxylamine; Diclegis/generic quantity limited to 120 tablets per 30 days (policy updates noted).
    • Document prior OTC trial and failures/intolerances in the medical record as part of the prior authorization submission.
    Prior trial requirement
    Requires trial and inadequate response or intolerance to generic aprepitant for oncology indications
    inv-29: Sancuso (granisetron transdermal system) — quantity limit
    Quantity limit1 transdermal system per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18 and moderate-to-high emetic risk
    Used withIntended for use in combination with a serotonin receptor antagonist (e.g., ondansetron)
    inv-30: Varubi (rolapitant) — quantity limit
    Quantity limit2 tablets per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18 and moderate-to-high emetic risk
    Used withMedication used in combination with dexamethasone and a serotonin receptor antagonist (e.g., ondansetron)
    inv-31: Bonjesta (doxylamine and pyridoxine ER) — quantity limit
    Quantity limit60 tablets per 30 days
    Step requirementRequires trial and inadequate response or intolerance to OTC pyridoxine + OTC doxylamine
    Indication contextTreatment of nausea and vomiting of pregnancy
    inv-32: Diclegis and generic doxylamine/pyridoxine DR — quantity limit
    Quantity limit120 tablets per 30 days (policy sections contain mixed references; history clarifies Diclegis and generic updated to 120/30 days)
    Step requirementRequires trial and inadequate response or intolerance to OTC pyridoxine + OTC doxylamine before coverage
    Indication contextTreatment of nausea and vomiting of pregnancy (Diclegis and generic delayed-release formulations)
    inv-33: Nereus (tradipitant) — quantity limit
    Quantity limit16 capsules per 30 days
    Dose limitDose limited to 170 mg daily
    Initial approvalInitial approval 30 days; subsequent courses evaluated as initial authorizations meeting same criteria
    inv-34: Akynzeo (netupitant and palonosetron) — quantity limit (history-confirmed)
    Quantity limit (history-confirmed)1 capsule per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18, moderate-to-high emetic risk, used with dexamethasone + 5-HT3 antagonist
    Source noteQuantity limit added during policy move from 5.01.605 to 5.01.662
    inv-35: Sancuso (granisetron transdermal system) — quantity limit (history-confirmed)
    Quantity limit (history-confirmed)1 transdermal system per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18 and moderate-to-high emetic risk
    Source noteQuantity limit added when criteria moved into this policy
    inv-36: Bonjesta (doxylamine and pyridoxine extended-release) — quantity limit (history-confirmed)
    Quantity limit (history-confirmed)60 tablets per 30 days
    Step requirementRequires trial and inadequate response or intolerance to OTC pyridoxine + OTC doxylamine
    Indication contextTreatment of nausea and vomiting of pregnancy
    inv-37: Diclegis and generic doxylamine/pyridoxine delayed-release — quantity limit (history-confirmed)
    Quantity limit (history-confirmed)120 tablets per 30 days
    Step requirementRequires trial and inadequate response or intolerance to OTC pyridoxine + OTC doxylamine
    Policy noteSome policy text referenced 60 tablets; history clarifies update to 120 tablets/30 days for Diclegis and generics
    inv-38: Varubi (rolapitant) — quantity limit (history-confirmed)
    Quantity limit (history-confirmed)2 tablets per fill
    Indication contextPrevention of nausea and vomiting associated with oncologic treatment when age ≥18 and moderate-to-high emetic risk
    Source noteQuantity limit added/updated when criteria moved into this policy
    inv-39: Nereus (tradipitant) — quantity limit (updated)
    Updated quantity limit16 capsules per 30 days (changed from prior 30 capsules/15 days)
    Dose limitDose limited to 170 mg daily
    Initial approvalInitial authorization for 30 days; additional courses re-evaluated as initial authorization
    Documentation Required

    Medical record documentation — office visit notes required

    Submit office visit notes that document the diagnosis, relevant history, physical evaluation, and medication history and that demonstrate the drug‑specific medical necessity criteria are met.

    • Include documentation of prior trials, inadequate responses, or intolerances when required by the product criteria.
    • Chart notes supporting continued clinical benefit are required for re‑authorization (up to 12 months when applicable).
    Documentation Required

    Required documentation — prior trials and failures

    When prior trials or failures are required by the product criteria, document those trials and the clinical outcome (inadequate response or intolerance) in the medical record to support prior authorization.

    • For Bonjesta/Diclegis/generics: document trial of OTC pyridoxine + doxylamine and outcome.
    • For Emend: document trial and inadequate response or intolerance to generic aprepitant.
    Denial Risk

    Denial risk — missing medical necessity documentation

    Failure to document that medical necessity criteria are met in the patient's medical record — including diagnosis, relevant history, physical evaluation, and medication history — may lead to denial of the request.

    • Include office visit notes and medication history with the prior authorization submission to avoid denial.
    Denial Risk

    Denial triggers — failure to meet product criteria or quantity limits

    Requests that do not meet the updated product‑specific criteria — including required prior trials and the stated quantity limits — may be denied; many coverage criteria were moved into this policy from the prior policy.

    • Verify quantity limits (e.g., Akynzeo 1 capsule per fill; Bonjesta 60/30 days; Diclegis/generic 120/30 days; Sancuso 1 system per fill) when submitting requests.
    • If criteria or limits are not met, consider documenting medical necessity rationale or alternative options prior to submission.
    Pathophysiology noteVomiting involves multiple pathways and neurotransmitters including 5-HT3 and NK1 receptors