5-HT3 Receptor Antagonists Prior Authorization Criteria (Platino)

General Prior Authorization Request Form

Covered Uses

All FDA approved indications not otherwise excluded form Part D:

• Ondansetron tablets - For the prevention of nausea and vomiting associated with
• moderately and highly emetogenic cancer chemotherapy
• radiotherapy
• the expectation that nausea or vomiting will occur post-operatively

Exclusion Criteria

For cancer patients, if the patients are not receiving chemotherapy and/or radiotherapy

Required Medical Information

Age Restrictions

None

Prescriber Restrictions

Oncologist - only if nausea and vomits are related to cancer chemotherapy or radiotherapy

Coverage Duration

Approved for six months and renewable.

Other Criteria

• Part D vs. Part B evaluation also applies to 5HT3 receptor antagonist - oral formulations
• Daily quantity to be covered will be according to the regimen approved by the FDA
  • ondansetron tablets and oral solution up to 8mg twice to three times daily or 24 mg once daily