ondansetron — CareFirst (Caremark)

Radiation therapy or moderate to highly emetogenic chemotherapy-associated nausea and vomiting

Initial criteria

For Hyperemesis Gravidarum: patient is pregnant AND patient has a documented risk for hospitalization AND request is for ondansetron or Zuplenz AND patient has experienced an inadequate treatment response, intolerance, or contraindication to TWO of the following: dimenhydrinate (Dramamine), diphenhydramine (Benadryl), doxylamine/pyridoxine delayed-release (Diclegis), doxylamine/pyridoxine extended-release (Bonjesta), metoclopramide (Reglan), promethazine (Phenergan), trimethobenzamide (Tigan), vitamin B6, vitamin B6 in combination with doxylamine.
For radiation therapy or moderate to highly emetogenic chemotherapy: authorization may be granted when the patient is receiving radiation therapy or moderate to highly emetogenic chemotherapy.

6 months