Sustol (granisetron extended-release injection) — CareFirst (Caremark)
moderately to highly emetogenic chemotherapy
Initial criteria
- For Hyperemesis Gravidarum: Authorization may be granted when ALL of the following are met:
- • The patient is pregnant.
- • The patient has a documented risk for hospitalization.
- • The request is for ondansetron.
- • The patient has experienced an inadequate treatment response, intolerance, or has a 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.
Approval duration
6 months