Clinical Policy: Tradipitant (Nereus)
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Defines medical necessity and prior authorization criteria for coverage of tradipitant (Nereus) for prevention of motion-induced vomiting in adults across QualChoice lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Initial Therapy
Covered when ALL of the following are met:
Illinois HIM requests are exempt from step therapy requirements per IL HB 5395
inv-02: Continuation Therapy
Approval duration: Not applicable
Non–FDA approved indications that are not specifically addressed in this policy are not authorized for coverage unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with the applicable off‑label use policies (for example, CP.CPA.09 for commercial, HIM.PA.154 for Health Insurance Marketplace, or CP.PMN.53 for Medicaid) or applicable evidence of coverage documents.
Initial Therapy
inv-14: Initial Therapy
Initial approval for motion sickness prevention requires all listed criteria.
Therapeutic alternatives listed in Appendix B; Illinois HIM requests exempt from step therapy per IL HB 5395
Continuation / Re-authorization
inv-15: Re-authorization
Approval duration: Not applicable
Provider Actions & Documentation
Prior authorization required; 7-day approval
Prior authorization is required for tradipitant (Nereus) for motion sickness prevention. Approval duration is 7 days. Re-authorization is not permitted; members must meet the initial approval criteria for any subsequent request.
- Approval duration: 7 days
- Re-authorization is not permitted; members must meet initial approval criteria for subsequent requests.
Step therapy: scopolamine then ≥2 antihistamines
Prior to approval, the member must have failed transdermal scopolamine unless it is contraindicated or causes clinically significant adverse effects. The member must also have failed at least two antihistamines used for motion sickness (examples: dimenhydrinate, meclizine, promethazine) unless contraindicated or associated with clinically significant adverse effects. Illinois HIM requests are exempt from these step therapy requirements per IL HB 5395.
- Failure of transdermal scopolamine required unless contraindicated or clinically significant adverse effects.
- Failure of ≥2 antihistamines (e.g., dimenhydrinate, meclizine, promethazine) required unless contraindicated or clinically significant adverse effects.
- IL HIM requests exempt from step therapy per IL HB 5395.
Include clinical documentation with PA request
Submit supporting clinical documentation with the prior authorization request, such as office chart notes, laboratory results, or other clinical information, that demonstrates the member meets all approval criteria for motion sickness prevention.
- Examples: office chart notes, lab results, or other clinical information showing planned event, prior therapy failures, age, and dosing/supply limits.
Missing documentation may lead to denial
Failure to provide the required documentation (office notes, laboratory results, or other clinical information) demonstrating that the approval criteria are met may result in denial of the request.
- Missing documentation showing criteria (e.g., prior therapy failures, planned event, age) may lead to denial.
Step Therapy Requirements
| Step | Requirement | Notes |
|---|---|---|
| 1 | Failure of transdermal scopolamine required prior to approval unless contraindicated or clinically significant adverse effects are experienced. | Illinois HIM requests are exempt from step therapy requirements per IL HB 5395. |
| Step | Requirement | Notes |
|---|---|---|
| 2 | Failure of ≥2 antihistamines used for motion sickness (e.g., dimenhydrinate, meclizine, promethazine) required prior to approval unless contraindicated or clinically significant adverse effects are experienced. | Illinois HIM requests are exempt from step therapy requirements per IL HB 5395. |
Dosing, Age, and Supply Limits
Quantity Limits
Background
Tradipitant (Nereus) is a substance P/neurokinin-1 (NK-1) receptor antagonist approved by the FDA for the prevention of vomiting induced by motion in adults. Labeled dosing includes single oral doses of 85 mg or 170 mg given approximately 60 minutes before an event expected to cause motion‑induced vomiting.
Definitions
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