UnitedHealthcare Antiemetics Coverage Prior Auth

Coverage Criteria for Antiemetic Medications

Initial coverage criteria

Covered when the following drug-class specific criteria are met

NK1 RA indication: NK1 RA (Cinvanti, Emend, Focinvez, Varubi) is indicated when either: (1) BOTH: prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents; AND in combination with a 5HT3 RA; OR (2) ALL: prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents; AND in combination with a 5HT3 RA; AND presence of one or more patient risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea or vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; or high anxiety).

From policy NK1 RA section.

5HT3 RA indication: 5HT3 RA (Aloxi, Kytril, Posfrea, Sustol, Zofran) is indicated when one of the following is met: (1) BOTH: prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents AND in combination with a NK1 RA; OR (2) prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents; OR (3) ALL: prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents AND in combination with a NK1 RA AND presence of one or more patient risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea or vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; or high anxiety); OR (4) treatment of breakthrough nausea and/or vomiting due to anticancer agents.

From policy 5HT3 RA section.

NK1/5HT3 combination (Akynzeo): NK1 RA/5HT3 RA combination product (Akynzeo) is indicated when either: (1) ALL: prevention of chemotherapy-induced nausea and vomiting due to Moderate Emetic Risk parenteral anticancer agents AND presence of one or more patient risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea or vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; or high anxiety); OR (2) prevention of chemotherapy-induced nausea and vomiting due to High Emetic Risk parenteral anticancer agents.

From policy NK1 RA/5HT3 RA combination section.

Non-preferred product authorization criteria

Non-preferred product may be medically necessary when either of the following are met

Trial failure path: Both: (1) History of a trial of adequate dose and duration to one preferred NK1 RA or 5HT3 RA product resulting in minimal clinical response; AND (2) Physician attests that, in their clinical opinion, the clinical response would be expected to be superior with the non-preferred NK1 RA, 5HT3 RA, or NK1 RA/5HT3 RA combination product than experienced with the preferred product.

Preferred Product Criteria - trial failure.

Intolerance/contraindication path: Both: (1) History of intolerance, contraindication, or adverse event to one preferred NK1 RA or 5HT3 RA product; AND (2) Physician attests that, in their clinical opinion, the same intolerance, contraindication, or adverse event would not be expected to occur with the non-preferred NK1 RA, 5HT3 RA, or NK1 RA/5HT3 RA combination product.

Preferred Product Criteria - intolerance/contraindication.

Guideline-specified prophylaxis by emetogenic risk

Covered when guideline-recommended combinations appropriate to the emetogenic risk are used

High emetic risk (IV): For high emetic risk parenteral (IV) anticancer agents, recommend category 1 regimens such as an NK1 antagonist (aprepitant oral or IV, fosaprepitant IV, or rolapitant oral) plus a 5-HT3 antagonist (palonosetron IV; granisetron SQ/oral/IV/transdermal; or ondansetron oral/IV) with dexamethasone oral or IV. Other options include netupitant/palonosetron or fosnetupitant/palonosetron with dexamethasone; or addition of olanzapine to palonosetron and dexamethasone. (NCCN; ASCO recommends a four-drug combination including olanzapine for HEC and AC regimens.)

(NCCN 2023; ASCO 2017/2020)

Moderate emetic risk (IV): For moderate emetic risk parenteral agents, options include a 5-HT3 antagonist plus dexamethasone (preference for palonosetron IV or granisetron extended-release injection when an NK1 antagonist is not used). Alternatives include an NK1 antagonist (aprepitant/fosaprepitant/rolapitant) plus a 5-HT3 antagonist and dexamethasone; netupitant/palonosetron or fosnetupitant/palonosetron with dexamethasone; or olanzapine-based regimens. Carboplatin AUC ≥4 may warrant NK1 inclusion per ASCO guidance.

(NCCN & ASCO 2023/2020)

Low emetic risk (IV):

Breakthrough therapy

Covered when escalation follows guideline recommendations for breakthrough symptoms

Breakthrough nausea/vomiting: Evaluate emetic risk, disease status, concurrent illnesses, and medications; if nausea/vomiting occurs despite prophylaxis and olanzapine was not used prophylactically, offer olanzapine in addition to continuing the standard antiemetic regimen. If olanzapine was used already, consider adding a drug from a different class (for example, an NK1 receptor antagonist, lorazepam or another benzodiazepine, a dopamine receptor antagonist, dronabinol, or nabilone) in addition to continuing the standard regimen.

(ASCO 2017)

This Medical Benefit Drug Policy does not apply to certain states. Providers should refer to the state-specific policy or guideline where noted for members in those jurisdictions and follow the local policy requirements rather than this national policy.

The FDA information included in this policy is provided for reference only. FDA approval alone is not a basis for coverage; FDA-labeled indications are informational and coverage decisions are determined by the plan’s medical necessity criteria and benefit terms.

Per NCCN guidance, routine prophylaxis is not recommended for parenteral agents with minimal emetogenic risk. For agents classified as minimal emetic risk, treat symptoms if they occur rather than providing scheduled preventive antiemetic therapy.

Billing and Code References

Applicable J- and Q-codesHCPCS

J0185	Injection, aprepitant, 1 mg.
J1434	Injection, fosaprepitant (Focinvez), 1 mg.
J1453	Injection, fosaprepitant, 1 mg.
J1454	Injection, fosnetupitant 235 mg and palonosetron 0.25 mg.
J1456	Injection, fosaprepitant (teva).
J1626	Injection, granisetron hydrochloride, 100 mcg.
J1627	Injection, granisetron, extended release, 0.1 mg.
J2405	Injection, ondansetron hydrochloride, per 1 mg.
J2468	Injection, palonosetron hydrochloride (posfrea), 25 mcg.
J2469	Injection, palonosetron HCl, 25 mcg.

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Applicable ICD-10 CodesICD-10

R11.0	Nausea.
R11.10	Vomiting, unspecified.
R11.16	Cannabis hyperemesis syndrome.
R11.2	Nausea with vomiting, unspecified.
T45.1X5A	Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter.
T45.1X5D	Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter.
T45.1X5S	Adverse effect of antineoplastic and immunosuppressive drugs, sequela.
Z51.11	Encounter for antineoplastic chemotherapy.

FDA-labeled Antiemetic Productsmixed

Akynzeo (netupitant/palonosetron)	Combination NK1 and 5-HT3 antagonist (capsule and injection) - FDA indicated for prevention of acute and delayed CINV.
Cinvanti (aprepitant) emulsion	Aprepitant NK1 receptor antagonist indicated for prevention of acute and delayed CINV.
Emend (fosaprepitant/aprepitant)	NK1 receptor antagonists indicated for prevention of acute and delayed CINV.
Varubi (rolapitant)	Rolapitant NK1 receptor antagonist indicated for prevention of delayed CINV.
Aloxi/Posfrea (palonosetron)	5-HT3 receptor antagonist indicated for prevention of acute and delayed CINV in specified settings.
Sustol (granisetron ER)	Granisetron extended-release injection indicated for prevention of acute and delayed CINV for MEC or AC regimens.
Kytril (granisetron)	Granisetron injection indicated for prevention of CINV.
Zofran (ondansetron)	Ondansetron oral and injection indicated for prevention of CINV and PONV in specified settings.

Emetogenic risk classification (IV vs oral differences)

IV agents - High>90% frequency of emesis

IV agents - Moderate30-90% frequency of emesis

IV agents - Low10-30% frequency of emesis

IV agents - Minimal<10% frequency of emesis

Carboplatin AUC

Carboplatin AUC thresholdAUC ≥ 4 classified as high emetic risk

Provider Actions and Utilization Management

Prior Authorization

Prior Authorization & Plan Verification

Prior authorization may be required for non-preferred NK1 RA, 5HT3 RA, or NK1 RA/5HT3 RA combination products. Verify member-specific benefit plan rules, applicable federal/state/contractual requirements, and the member's plan/contract prior to submission; plan or contract terms govern if there is a conflict with this policy.

Check the member's specific plan/contract for prior authorization requirements and any plan-specific limits or exclusions.
Federal, state, or contractual requirements may override this policy — document and follow those requirements when they apply.

Step Therapy

Step Therapy Requirement

Step therapy applies: a trial of a preferred NK1 RA or a preferred 5HT3 RA at an adequate dose and duration is required prior to approval of a non-preferred NK1 RA, 5HT3 RA, or NK1 RA/5HT3 RA combination product, unless there is documented intolerance, contraindication, or an attested expectation of superior response to the non-preferred product.

Covered Regimens and Line of Therapy

any

Use with the following lines of therapy

Use with High emetic risk IV chemotherapy: Use as part of the recommended antiemetic regimen for prevention of acute and delayed emesis with high emetic risk parenteral agents, in combination with a 5HT3 RA and dexamethasone (and possibly olanzapine) per NCCN recommendations.

first-line

First-line use per FDA-labeled indications

Prevention for initial and repeat courses: Many FDA-labeled indications specify use in adults for prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of chemotherapy (HEC and MEC).

FDA product labeling

Regimen	Recommended components	Alternatives / notes
Aprepitant (oral or IV) or fosaprepitant IV or rolapitant oral
NK1 antagonist (aprepitant/fosaprepitant/rolapitant) + 5-HT3 receptor antagonist (palonosetron IV; granisetron SQ/oral/IV/transdermal; or ondansetron oral/IV) + dexamethasone (oral or IV)
Other options: netupitant/palonosetron oral or fosnetupitant/palonosetron IV with dexamethasone; regimens adding olanzapine; combinations listed as NCCN category 1 for HEC (NCCN, 2023)

Regimen	Recommended components	Alternatives / preference notes
5-HT3 receptor antagonist + dexamethasone
Preference for palonosetron IV or granisetron extended-release injection when an NK1 antagonist is not used
Alternatives: include an NK1 antagonist (aprepitant/fosaprepitant/rolapitant) with a 5-HT3 antagonist and dexamethasone; netupitant/palonosetron or fosnetupitant/palonosetron with dexamethasone; or olanzapine-based regimens (NCCN, 2023)

Regimen	Recommended components	Guideline reference / use case
Four-drug combination for HEC/AC regimens
NK1 antagonist + 5-HT3 antagonist + dexamethasone + olanzapine
Recommended by ASCO and NCCN for highly emetogenic chemotherapy or AC regimens as a preferred four-drug prophylactic regimen

Regimen	Recommended components	Considerations
Moderate emetic risk regimens
5-HT3 antagonist + dexamethasone
Consider inclusion of an NK1 antagonist for certain agents (e.g., carboplatin AUC ≥ 4); when NK1 not used, prefer palonosetron IV or granisetron ER injection (NCCN, 2023)

Key Definitions

Acute Emesis

TimingNausea and/or vomiting that occurs within a few minutes to several hours after administration of anticancer agents and commonly resolves within the first 24 hours.

Clinical contextCorresponds to immediate-onset post-chemotherapy symptoms addressed by acute prophylaxis regimens.

NCCN/ASCO relevanceUsed to classify emetogenic risk and select acute antiemetic regimens.

Delayed Emesis

TimingNausea and/or vomiting that occurs more than 24 hours after anticancer agents.

Clinical contextRepresents delayed emesis requiring antiemetic strategies that cover >24 hours post-treatment.

Background

Chemotherapy- and radiation-related nausea and vomiting vary by the emetogenic potential of the anticancer agent, dose and route of administration, the anatomic site and dose of radiation, and patient-specific factors such as younger age, female sex, prior CINV, low prior alcohol use, history of motion sickness or morning sickness, and high anxiety. Antiemetic classes addressed in this policy include NK1 receptor antagonists, 5-HT3 receptor antagonists, and combination NK1/5-HT3 products used to prevent both acute and delayed emesis according to guideline-recommended regimens for high- and moderate-emetic-risk treatments.

OpenPayer

Antiemetics for Oncology