Antiemetics, Newer

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
ONDANSETRON ONDANSETRON ODT TAB RAPDIS Y Quantity Limit  
ONDANSETRON ZOFRAN ODT TAB RAPDIS Y Quantity Limit  
ONDANSETRON HCL ZOFRAN SOLUTION Y Quantity Limit  
ONDANSETRON HCL ONDANSETRON HCL SOLUTION Y Quantity Limit  
ONDANSETRON HCL ZOFRAN TABLET Y Quantity Limit  
ONDANSETRON HCL ONDANSETRON HCL TABLET Y Quantity Limit  
APREPITANT EMEND CAP DS PK N Quantity Limit  
APREPITANT APREPITANT CAP DS PK N Quantity Limit  
APREPITANT EMEND CAPSULE N Quantity Limit  
APREPITANT APREPITANT CAPSULE N Quantity Limit  
APREPITANT EMEND SUSP RECON N Quantity Limit  
DOLASETRON MESYLATE ANZEMET TABLET N Quantity Limit  
DOXYLAMINE SUCCINATE/VIT B6 DICLEGIS TABLET DR N Quantity Limit  
FOSAPREPITANT DIMEGLUMINE EMEND VIAL N Quantity Limit  
GRANISETRON SUSTOL LIQ ER SYR N Quantity Limit  
GRANISETRON SANCUSO PATCH TDWK N Quantity Limit  
GRANISETRON HCL GRANISETRON HCL TABLET N Quantity Limit  
NETUPITANT/PALONOSETRON HCL AKYNZEO CAPSULE N Quantity Limit  
ONDANSETRON ZUPLENZ FILM N Quantity Limit  
ROLAPITANT HCL VARUBI TABLET N Quantity Limit  
GRANISETRON HCL GRANISETRON HCL VIAL Quantity Limit  
GRANISETRON HCL/PF GRANISETRON HCL VIAL Quantity Limit  
ONDANSETRON HCL ZOFRAN VIAL Quantity Limit  
ONDANSETRON HCL ONDANSETRON HCL VIAL Quantity Limit  
ONDANSETRON HCL/PF ONDANSETRON HCL SYRINGE Quantity Limit  
ONDANSETRON HCL/PF ONDANSETRON HCL VIAL Quantity Limit  
PALONOSETRON HCL ALOXI VIAL Quantity Limit