5-HT3 Receptor Antagonists Prior Authorization Criteria (Preferred)

General Prior Authorization Request Form

Covered Uses

• Dolasetron tablets - For the prevention of nausea and vomiting associated with
  • moderately emetogenic cancer chemotherapy, including initial and repeat courses
  • the expectation that nausea or vomiting will occur post-operatively
• Granisetron tablets and oral solution - For the prevention of nausea and vomiting associated with
  • initial and repeat courses of emetogenic cancer chemotherapy, including high dose cisplatin
  • with radiotherapy
• Ondansetron tablets and oral solution - 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
  • dolasetron tablets up to a maximum dose of 100mg/day
  • granisetron tablets and oral solution up to a maximum of 1mg twice daily or 2mg once daily
  • ondansetron tablets and oral solution up to 8mg twice to three times daily or 24 mg once daily