- Step Therapy: Chemo-induced Nausea and Vomiting (CINV):
ST Multiple Generics
- Prior Authorization: Chemo-induced Nausea and Vomiting (CINV):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Day(s)
Reauthorization Required: Yes
HIV Wasting:
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy Exists in PA
- 1. Health Net Approved Indications and Usage Guidelines: a. Treatment of nausea and vomiting associated with cancer chemotherapy: i. Patient has received highly or moderately emetogenic chemotherapy and was intolerant or refractory to 5HT3 serotonin antagonist (e.g., ondansetron), in combination with Emend and dexamethasone; AND ii. Failure or clinically significant adverse effects to TWO of the following: metoclopramide, prochlorperazine or lorazepam. b. Treatment of anorexia with weight loss in patients with AIDS: i. Use of Marinol is for appetite stimulation for AIDS; AND ii. Failure or clinically significant adverse effects to megestrol. 2. Authorization Limit: a. Nausea & vomiting: As specified by length of chemotherapy. b. Appettite Simulant: Length of Benefit.
- Chemo-induced Nausea and Vomiting (CINV):
Age Requirement: >= 18
Duration: 3 Day(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: >= 3 day(s)
NV associated with highly emetogenic cancer chemotherapy (HEC): No
NV associated with moderately emetogenic cancer chemotherapy (MEC): No
Concomitant therapy with Corticosteroid: No
Concomitant therapy with 5-HT3 Antagonist: No
HIV Wasting:
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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