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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

October 2018

Updates to Antiemetic Therapy Medical Review Criteria

Harvard Pilgrim is updating our commercial prior authorization medical review criteria for antiemetic therapy medications, which are indicated for the treatment of nausea and vomiting, commonly in oncology patients.

For dates of service beginning Dec. 1, 2018, the injectable forms of the drugs Cinvanti, Sustol, and Varubi will be covered with prior authorization, when all specific criteria outlined on the policy are met. This coverage is reflected via the addition of the following codes:

  • C9463 – Injection, aprepitant, 1 mg (Cinvanti)
  • J1627 – Injection, granisetron, extended-release, 0.1 mg (Sustol)
  • C9464 – Injection, rolapitant, 0.5 mg (Varubi)

Additionally, Harvard Pilgrim is removing Anzemet (J1260 – Injection, dolasetron mesylate, 10 mg) from the policy because the medication is no longer available on the market. The following codes for the medications Aloxi and Emend will remain on the policy, and will continue to be covered with prior authorization:

  • J2469 – Injection, palonosetron HCl, 25 mcg (Aloxi)
  • J1453 – Injection, fosaprepitant, 1 mg (Emend)

To request authorization for any of these medications, please contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882).

For more information, including criteria and prior authorization request forms, please refer to the Medical Drug Prior Authorization page in the Provider section of Harvard Pilgrim’s website.

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