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Table 27: Antiemetics, Appetite Stimulants, and Anabolics


A    B    C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S    T    U    V    W    X    Y    Z


Drug Category: Gastrointestinal

Medication Class/Individual Agents: Antiemetics/5-HT3 Receptor Antagonists, Appetite Stimulants, and Anabolics

I. Prior-Authorization Requirements

 Antiemetics, Appetite Stimulants, and Anabolics – 5-HT3 Receptor Antagonists

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

granisetron extended-release injection Sustol PA   - > 2 units/28 days
granisetron injection test  
granisetron tablet PA   - > 2 tablets/28 days A90
granisetron transdermal system Sancuso PA  
ondansetron 24 mg tablet PA   A90
ondansetron 4 mg, 8 mg tablet Zofran test   # , A90
ondansetron injection test  
ondansetron orally disintegrating tablet test   A90
ondansetron solution PA   A90
palonosetron 0.25 mg/2 mL injection PA   - > 2 units/28 days A90
palonosetron 0.25 mg/5 mL injection Aloxi PA   - > 2 units/28 days #

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • Granisetron oral formulations are FDA approved for the prevention/treatment of chemotherapy-induced and radiation-induced nausea and vomiting.
  • Ondansetron is FDA approved for the prevention/treatment of postoperative, chemotherapy-induced, and radiation-induced nausea and vomiting.
  • Netupitant/palonosetron is FDA approved for prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV).
  • Rolapitant is FDA approved in combination with other antiemetic agents for prevention of delayed CINV.
  • Dronabinol is an orally active cannabinoid that is FDA approved for the treatment of cancer chemotherapy induced nausea and vomiting in members with an inadequate response to conventional antiemetic treatments.
  • Dronabinol is also FDA approved for the management of anorexia associated with weight loss in members with acquired immune deficiency syndrome (AIDS).
  • Orally active cannabinoids are recommended by the National Comprehensive Cancer Network (NCCN) as an option for the treatment of breakthrough nausea and vomiting as an addition to the appropriate prophylactic regimen of conventional antiemetics that is based upon emetogenicity of the chemotherapy regimen. The NCCN recommends that consideration can be given to the use of a cannabinoid in palliative care members; however, the NCCN recognizes that the use of cannabinoids in members with cancer-related anorexia has limited data to support this use.
  • Oxandrolone is FDA approved for adjunctive therapy to promote weight gain after weight loss following extensive surgery, chronic infections, or severe trauma, and in some members who, without definite pathophysiologic reasons, fail to gain or to maintain normal weight; to offset protein catabolism with prolonged corticosteroid administration; relief of bone pain associated with osteoporosis.
  • For the treatment of nausea and vomiting of pregnancy, initial pharmacotherapy includes pyridoxine. The combination of doxylamine and pyridoxine could be used when pyridoxine monotherapy fails to improve symptoms.
 

 Antiemetics, Appetite Stimulants, and Anabolics – Not Otherwise Classified

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

aprepitant 125 mg powder for oral suspension Emend PA   - > 6 units/28 days A90
aprepitant 40 mg, 125 mg capsule PA   - > 2 capsules/28 days A90
aprepitant 80 mg Emend PA   - > 4 capsules/28 days # , A90
aprepitant injectable emulsion Cinvanti PA  
aprepitant trifold pack Emend PA   - > 2 packs/28 days BP, A90
doxylamine / pyridoxine delayed-release Diclegis PA   BP, A90
doxylamine / pyridoxine extended-release Bonjesta PA  
dronabinol capsule Marinol PA  
fosaprepitant injection Emend PA   - > 2 vials/28 days #
fosnetupitant / palonosetron injection Akynzeo PA   - > 2 vials/28 days
megestrol 40 mg/mL suspension test   A90
megestrol 625 mg/5 mL suspension PA   A90
netupitant / palonosetron capsule Akynzeo PA   - > 2 capsules/28 days
oxandrolone PA  
rolapitant injection Varubi PA   - > 2 vials/28 days
scopolamine transdermal patch Transderm-Scop test   BP, A90
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • AIDS-associated anorexia, cachexia, or weight loss
  • Chemotherapy-induced nausea and vomiting (CINV)
  • Nausea and vomiting of pregnancy (NVP)
  • Osteoporosis-related bone pain
  • Postoperative nausea and vomiting (PONV)
  • Prevent weight loss/promote weight gain
  • Radiation-induced nausea and vomiting (RINV) 

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply. 
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis (see below).

  

Akynzeo, fosaprepitant injection, granisetron tablet, palonosetron, Sustol, and Varubi vials > 2 units/28 days

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • medical necessity for exceeding the quantity limit.

 

aprepitant 40 mg capsule, 125 mg capsule, and trifold pack > 2 units/28 days

  • Documentation of one of the following is required:
    • diagnosis of CINV.

 

aprepitant 80 mg capsule > 4 capsules/28 days

  • Documentation of one of the following is required:
    • diagnosis of CINV.

SmartPA: Claims for aprepitant (40 mg, 80 mg, 125 mg, trifold pack) above the established quantity limits will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims history of an antineoplastic medication in the last 60 days or has MassHealth medical claims for a CPT code for chemotherapy administration in the last 60 days.

 

Bonjesta and doxylamine/pyridoxine delayed-release

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response to combination therapy with doxylamine and pyridoxine; and
    • for Bonjesta, inadequate response or adverse reaction to doxylamine/pyridoxine delayed-release.

 

Cinvanti

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to aprepitant or fosaprepitant.

 

dronabinol capsule

  • Documentation of all of the following is required for a diagnosis of AIDS-associated anorexia:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to megestrol. 
  • Documentation of all of the following is required for a diagnosis of CINV:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to two conventional antiemetics at least one of which must be a 5-HT3 receptor antagonist. 

 

Emend 125 mg powder for oral suspension > 6 units/28 days

  • Documentation of one of the following is required:
    • diagnosis of CINV.

SmartPA: Claims for Emend 125 mg powder for oral suspension above the established quantity limits will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims history of an antineoplastic medication in the last 60 days or has MassHealth medical claims for a CPT code for chemotherapy administration in the last 60 days.

 

megestrol 625 mg/5 mL suspension

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response, adverse reaction, or contraindication to megestrol 40 mg/mL suspension or tablet. 
  • For recertification, documentation of the following is required:
    • positive response to therapy including weight gain or no net weight loss from baseline; or
    • clinical rationale for continued therapy depsite weight loss.

 

ondansetron 24 mg tablet

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • clinical rationale why ondansetron 8 mg tablet or ondansetron 8 mg ODT (three units) cannot be utilized.

 

ondansetron solution

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • medical necessity for the use of the solution formulation as noted by one of the following:
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • member is < 13 years of age; or
      • clinical rationale why conventional dosage forms cannot be used.

 

oxandrolone

  • Documentation of all of the following is required for a diagnosis of promoting weight gain/preventing weight loss in adult members: 
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • significant weight loss as defined by one of the following:
      • body mass index (BMI) ≤ 20 kg/m2; or
      • involuntary loss of ≥ 10% of premorbid body weight; or
      • involuntary loss of ≥ 5% of body weight within six months; and
    • inadequate response (defined by at least four weeks of therapy), adverse reaction, or contraindication to megestrol. 
  • Documentation of all of the following is required for a diagnosis of promoting weight gain/preventing weight loss in pediatric members:
    • appropriate diagnosis; and
    • member is < 18 years of age.
  • Documentation of all of the following is required for a diagnosis of osteoporosis-related bone pain:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to two or contraindication to all of the following: acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), calcitonin.

 

Sancuso

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to ondansetron ODT.

 

IV.  Pediatric Members

  • ondansetron (Zofran) is FDA-approved for chemotherapy-associated nausea and vomiting in children ≥ four years old; however weight based dosing (I.V. product) is available for children ≥ six months old.
  • promethazine and prochlorperazine are FDA-approved for use in children ≥ two years old. 

 

Conventional Antiemetics (not all inclusive)

Antihistamines

Prokinetic

Phenothiazines

Anticholinergics

dimenhydrinate

diphenhydramine

hydroxyzine

meclizine

metoclopramide

prochlorperazine

promethazine

scopolamine

trimethobenzamide

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 12/2003

Last Revised Date: 09/2022


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Last updated 10/31/22

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