Zuplenz — CareFirst (Caremark)
Prevention or treatment of nausea and vomiting associated with radiation therapy
Preferred products
- dimenhydrinate
- diphenhydramine
- doxylamine/pyridoxine delayed-release (Diclegis)
- doxylamine/pyridoxine extended-release (Bonjesta)
- metoclopramide
- promethazine
- trimethobenzamide
- vitamin B6
- vitamin B6 with doxylamine
Initial criteria
- Patient is receiving radiation therapy OR moderate to highly emetogenic chemotherapy OR is pregnant with the diagnosis of hyperemesis gravidarum and has documented risk for hospitalization
- If request is for ondansetron or Zuplenz for hyperemesis gravidarum, patient has experienced 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, or vitamin B6 in combination with doxylamine
Approval duration
6 months