Antiemetics

Document Utilities

Pharmacy Clinical Policy Bulletins

Subject: Antiemetics

Class Edit Summary*

Status Drug PR PR-QL PR-AL ST M EX‡

P metoclopramide

P prochlorperazine

P promethazine

P trimethobenzamide

P Zofran® (ondansetron) X

P Zofran ODT® (ondansetron) X

NP Compazine® (prochlorperazine)

NP Phenergan® (promethazine)

NP Reglan® (metoclopramide)

NP Tigan® (trimethobenzamide)

FE Anzemet® (dolasetron) X X

FE Emend® (aprepitant) X X

FE Kytril® (granisetron) X X

FE Transderm Scop® (scopalamine) X

Non-prescription (OTC) products available (NOT covered under standard benefit plans)

OTC Dramamine OTC

*P = Preferred; FE = Formulary Excluded; NP = Nonpreferred
PR = Precertification; QL = Quantity Limits; AL = Age Limits; ST = Step-Therapy
‡M EX = Medical Exception - This means the physician or health care professional must obtain a medical exception from Aetna, in order for the medication to be eligible for coverage. Medical Exception criteria apply to Formulary Excluded drugs for members enrolled in or covered by closed benefits plans, and also apply to Step-Therapy drugs in cases where a member's physician believes it is medically necessary for the member to use a step-therapy drug in the first instance without a trial of the prerequisite alternative drug(s).

Important Note

This Pharmacy Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefits plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their health care providers will need to consult the member's benefits plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members. CMS's Coverage Database can be found on the following website: http://www.cms.hhs.gov/center/coverage.asp.

Policy

Precertification Criteria

Under some plans, including plans that use an open or closed formulary, Anzemet, Emend, Kytril, Zofran and Zofran ODT are subject to precertification. If precertification requirements apply Aetna considers Anzemet, Emend, Kytril, Zofran and Zofran ODT to be medically necessary for those members who meet the following precertification criteria:

Quantity limits:
According to the manufacturers, the antiemetics Anzemet, Emend, Kytril, Zofran and Zofran ODT can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of each drug will be considered medically necessary as indicated in the table below,


Drug	Maximum Daily Dose/ Dosing Interval	Dosage Strength	Quantity Limits

Anzemet	100 mg/ Once daily	50 mg, 100 mg	Up to 5 tablets in 30 days

Emend	3-day regimen, 125 mg on day 1 and 80 mg on days 2 and 3 of the chemotherapy regimen	80 mg, 125 mg	Up to 5 capsules in 30 days

Emend	3-day regimen, 125 mg on day 1 and 80 mg on days 2 and 3 of the chemotherapy regimen	80 mg, 125 mg (tri-fold pack)	Up to 2 packs (6 capsules)/30 days

Kytril	2 mg /Once or twice daily	1 mg	Up to 10 tablets per 30 days

Kytril	2 mg /Once or twice daily	2 mg/10ml	Up to 5 (10ml) doses per 30 days

Zofran, Zofran ODT	8mg/ Twice to three times daily	4 mg, 8 mg	Up to 12 tablets per 30 days

Zofran	24mg/ Once daily	24 mg	Up to 5 tablets per 30 days

Zofran	8mg/ Twice to three times daily	4 mg/5ml	Up to 10 (5ml) doses per 30 days

For coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. Additional quantities of the antiemetics Anzemet, Emend, Kytril, Zofran and Zofran ODT will be considered medically necessary for those members who meet the criteria specified below:

For Anzemet, Kytril and Emend

Member has a chemotherapy regimen:
- with doses on more than 5 days per 30 days OR
- with doses more frequently than two times per 30 days
- that requires more than one cycle of antiemetic per 30 days
OR
Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose or a longer duration of therapy.

For Zofran and Zofran ODT

Member is receiving chemotherapy or radiation therapy for cancer diagnosis and requires greater quantity
OR
Member has hyperemesis gravidarum and meets ALL of the following criteria (approval will be made for 120 tablets for a 30-day supply duration (max time of approval of 3 months); approval is renewable if criteria continue to be met):
1. Parenteral hydration would otherwise be necessary or has already been tried AND
2. Ineffectiveness of non-pharmacological therapies is documented. Non-pharmacological therapies include, but are not limited to, small meals low in fat, high in carbohydrates, and bedrest AND
3. Vomiting despite adequate treatment with at least two of the following antiemetics:
  AND
4. Weight loss has occurred.
OR
Member has hyperemesis gravidarum and meets ALL of the following criteria (approval will be made for 120 tablets for a 30-day supply duration (max time of approval of 3 months); approval is renewable if criteria continue to be met):
1. Patient is being released from the hospital and is being transitioned to oral zofran from i.v. zofran or zofran pump
Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose or a longer duration of therapy.

Medical Exception Criteria
Anzemet, Emend, Kytril and Transderm Scop are currently listed on the Aetna Formulary Exclusions List.* Therefore, Anzemet, Emend, Kytril and Transderm Scop are excluded from coverage for members enrolled in prescription drug benefits plans that use a closed formulary, unless a medical exception is granted. Aetna considers Anzemet, Emend, Kytril and Transderm Scop to be medically necessary for those members who meet any of the following criteria:
1. A documented:
  - Contraindication to one preferred alternative antiemetic agent indicated for the member's condition OR
  - Intolerance to one preferred alternative antiemetic agent indicated for the member's condition OR
  - Allergy to one preferred alternative antiemetic agent indicated for the member's condition OR
  - Failure of an adequate trial of one day or one course of one preferred alternative antiemetic agent indicated for the member's condition OR
  - Member is being treated as terminal care and requires transdermal Transderm Scop

*Information regarding Aetna's Preferred Drug List, Formulary Exclusions list, Precertification and Step-Therapy lists is available on our website. In addition, members should refer to their plan documents and may call the toll-free telephone number on their ID card for information regarding their benefits. Health care professionals also may obtain information by calling the Pharmacy Management Precertification Unit at 1-800-414-2386, or they can register to use our password-protected provider website. Visit www.aetna.com, select "Doctors & Hospitals" and choose "Physician Self-Service." Once registration is completed, health care professionals may use our online Precertification/medical exception email request form.

The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas (for example, step-therapy does not apply to fully insured New Jersey members).

Many medications on the Preferred Drug List are subject to manufacturer rebate arrangements between Aetna and the manufacturer of those medications. If the member's prescription benefits plan has a deductible or copay levels based on a percentage of Aetna's contracted rate with the participating pharmacy, the contracted rate does not include or reflect any manufacturer rebate arrangements between Aetna and the medication manufacturer. In prescription plans with a deductible or copayment or coinsurance tiers, use of drugs from the Preferred Drug List generally will result in lower costs to members. However, where the prescription plan utilizes a deductible or copayments or coinsurance calculated on a percentage basis, there could be some circumstances in which a preferred drug would cost the member more than a nonpreferred drug because (1) the negotiated pharmacy payment rate for the preferred drug may be more than the negotiated pharmacy payment rate for the nonpreferred drug, and (2) rebates received by Aetna from drug manufacturers are not reflected in the cost of a prescription drug obtained by a member. The Preferred Drug List is subject to change.

In evaluating clinically and therapeutically similar drugs for selection for the Preferred Drug List, Aetna reviews the costs of drugs and takes into account rebates negotiated between Aetna and drug manufacturers. Consequently, a drug may be included on the Preferred Drug list that is more expensive than a nonpreferred alternative before any rebates Aetna may receive from a drug manufacturer are taken into account. In addition, certain drugs may be chosen for "preferred" status because of their clinical or therapeutic advantages or level of acceptance among physicians even though they cost more than nonpreferred alternatives. The net cost to a self-funded plan sponsor for covered prescriptions will vary based on (1) the terms of Aetna's arrangements with participating pharmacies; (2) the amount of the member's copayment, coinsurance or deductible obligation under the terms of the plan; and (3) the percentage, if any, of rebates to which the plan sponsor is entitled under its agreement with Aetna. As a result, a self-funded plan sponsor's actual claim expense per prescription for a particular preferred drug may in some circumstances be higher than for a nonpreferred alternative.

For members in Texas, additions to the 2006 Preferred Drug List will be effective no later than January 1, 2006. In accordance with state law, fully insured members in Texas who are receiving coverage for medications that are removed from the Preferred Drug List during the plan year will continue to have those medications covered at the same benefit level until their plan's renewal date.

This definition of precertification is not the same as the definition used by Texas law. Our use of the term "precertification" relates to the prior authorization of your services by Aetna, based on our decision of whether the service is medically necessary. Precertification is not a guarantee of payment or "verification" as defined by Texas law.

California HMO members enrolled in a closed formulary benefits plan who are receiving coverage for medications that are moved to the Formulary Exclusions List, and California HMO members who are receiving coverage for medications added to the Precertification or Step-Therapy lists, will continue to have those medications covered, for as long as the treating physician continues prescribing them. This coverage, in accordance with state law, is only provided when the drug is appropriately prescribed and is considered safe and effective for treating the member's medical condition.

Nothing in this section shall preclude the prescribing health care professional from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions.

Place of Service:

Outpatient

The above policy is based on the following references:

Olin BR, editor. Drugs Facts and Comparisons (electronic online version). St. Louis: J.B. Lippincott Company, 2005.
USPDI Drug Information for the HealthCare Professional (online through Stat!Ref). Thomson MICROMEDEX, Greenwood Village, Colorado; 2005.
McEvoy GK, editor. AHFS Drug Information (online through Stat!Ref). American Society of Health-Systems Pharmacists, Bethesda, Maryland; 2005.
Emend Prescribing Information. Merck. Whitehouse Station, NJ, March 2003.
Transderm-Scop Prescribing Information. Novartis, Summit, NJ, August 2003.
ASHP Therapeutic Guidelines on the Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving Chemotherapy or Radiation Therapy or Undergoing Surgery. 1999;56:730-64
Kranke P. The efficacy and safety of transdermal scopolamine for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anest Analg. 2002;95:133-43.
Goodin S, Cunningham R. 5-HT(3)-receptor antagonists for the treatment of nausea and vomiting: a reappraisal of their side-effect profile. Oncologist. 2002;75(5):424-36.
Magee LA, Mazzotta P, Koren G. Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of pregnancy (NVP). Am J Obstet Gynecol. 2002;186:S256-61.
Koch KL, Frissora CL. Nausea and vomiting during pregnancy. Gastroenterol Clin North Am. 2003;32:201-34.
Quinlan JD, Hill DA. Nausea and vomiting during pregnancy. Am Fam Physician. 2003;68:121-8.
Chawla SP, Grunberg SM, Gralla RJ, et al. Establishing the dose of the oral NK1 antagonist aprepitant for the prevention of chemotherapy-induced nausea and vomiting. Cancer. 2003;97(9):2290-300.
Poli-Bigelli S, Rodrigues-Pereira J, Carides AD, et al. Addition of the neurokinin 1 receptor antagonist aprepitant to standard antiemetic therapy improves control of chemotherapy-induced nausea and vomiting. Results from a randomized, double-blind, placebo-controlled trial in Latin America. Cancer. 2003;97(12):3090-8.
Navari RM, Koeller JM. Electrocardiographic and cardiovascular effects of the 5-hydroxytryptamine-3 receptor antagonists. Ann Pharmacother. 2003; 37(9):1276-86.
Medical Economics, Inc., PDR Electronic Library. Thomson Medical Economics, Montvale, NJ; 2003.

Property of Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

March 1, 2006