Antiemetics
January 2013
PA criteria for nonpreferred drugs: Oral 5HT3 antagonists
Preferred
| Drug name |
Dosage form and strength |
| generic ondansetron/ondansetron ODT |
4 mg, 8 mg tablets/ ODT tablets |
| *ODT = orally disintegrating tablets |
|
Nonpreferred
| Drug name |
Dosage form and strength |
| Anzemet (dolasetron) |
50 mg and 100 mg tablets |
| granisetron |
1 mg tablets |
| Granisol (granisetron) |
Oral solution 1mg/5mL |
| Sancuso (granisetron) |
Patch 3.1 mg ($372.00 per patch) |
| Zofran (ondansetron) |
4 mg, 8 mg tablets/ODT |
| Zuplenz (ondansetron) |
4 mg, 8 mg Disintegrating film |
Criteria for nonpreferred drugs: Oral 5HT3 antagonists
Granisetron tablets and oral solution (recommended first nonpreferred)
- Use of ondansetron (tablets, ODT, oral solution) resulted in therapeutic failure or significant adverse effects
Sancuso (granisetron) Patch
- Patient is undergoing chemotherapy AND has experienced failure on every other oral formulation of ondansetron and granisetron or can take nothing by mouth
Any branded, nonpreferred antiemetic
- Use of ondansetron tabs and ODT resulted in therapeutic failure or significant adverse effects
- AND use of granisetron resulted in therapeutic failure or significant adverse effects
- AND for Zofran (brand) requests: patient meets DAW/Branded Criteria
- OR for Zuplenz, patient is undergoing chemotherapy or radiation therapy or is status post-surgery
Antiemetic quantity limits
5-HT3 antagonists: Anzemet, granisetron, Zofran, Zuplenz
- Quantity limits on nonpreferred oral (tablets or ODT) dosage forms
- Quantity limits will be 20 oral dosage forms of all products per rolling calendar month.
- Quantity limit on ondansetron oral solution (4mg/5mL) = 200 mL per month
Criteria for QL override:
- Preferred drug criteria have been met
- AND Chemotherapy or radiation therapy cycles that require more frequent dosing of 5 HT3 antiemetics than can be treated by 20 tablets per month
- OR Patient is experiencing hyperemesis of pregnancy. Number of fills not to exceed pregnancy
- OR Patient is not being treated for cancer, then the patient must have well documented use of rational alternatives
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411
