Antiemetics
PHARM-13 Statement of Medical Necessity for Quantity Limits Override.
| Antiemetics |
Drugs |
Quantity Limits |
Aloxi (Palonosetron HCL) 0.075mg/1.5ml Vial |
4 Vials (6mls) per 28 days |
Aloxi (Palonosetron HCL) 0.25mg/5ml Vial |
4 Vials (20mls) per 28 days before chemotherapy |
Anzemet (Dolasetron Mesylate) 50mg and 100mg Tablets |
2 Tablets per day up to 5 days |
Emend (Aprepitant) 125mg-80mg Convenience Pack Capsules |
2 packs per 30 days |
Emend (Aprepitant) 40mg, 80mg and 125mg Capsules |
1 pack per 30 days |
Emend (Fosaprepitant Dimeglumine) 115mg Vial |
1 Vial per 30 days |
Granisol (Granisetron) 1mg/5ml Solution |
30mls per 10 days |
Kytril (Granisetron HCL) 1mg Tablets |
2 Tablets per day up to 10 days |
Sancuso (Granisetron Transderm) 3.1mg/24hr Patch |
1 Patch per 21 days |
Zofran (Ondansetron HCL) 4mg, 8mg and 24mg Tablets |
4mg and 8mg - 12 Tablets per 30 days 24mg - 1 Tablet per 1 day in 30 day period |
Zofran (Ondansetron HCL) 4mg/5ml Solution |
50 Mls per 28 days |
Zofran ODT (Ondansetron HCL) 4mg and 8mg Rapdis Tablets |
12 Tablets per 30 days |
Last Modified on
Nov 17, 2020
