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    
ondansetron ZOFRAN ODT TAB RAPDIS Y    
ondansetron HCl ZOFRAN SOLUTION Y    
ondansetron HCl ONDANSETRON HCL SOLUTION Y    
ondansetron HCl ONDANSETRON HCL TABLET Y    
ondansetron HCl ZOFRAN TABLET Y    
aprepitant APREPITANT CAP DS PK N PA Document  
aprepitant EMEND CAP DS PK N PA Document  
aprepitant APREPITANT CAPSULE N PA Document  
aprepitant EMEND CAPSULE N PA Document  
aprepitant EMEND SUSP RECON N PA Document  
dolasetron mesylate ANZEMET TABLET N PA Document  
doxylamine succinate/vit B6 BONJESTA TAB IR DR N PA Document  
doxylamine succinate/vit B6 DICLEGIS TABLET DR N PA Document  
granisetron SUSTOL LIQ ER SYR N PA Document  
granisetron SANCUSO PATCH TDWK N PA Document  
granisetron HCl GRANISETRON HCL TABLET N PA Document  
netupitant/palonosetron HCl AKYNZEO CAPSULE N PA Document  
ondansetron ZUPLENZ FILM N PA Document  
rolapitant HCl VARUBI TABLET N PA Document  
aprepitant CINVANTI VIAL    
fosaprepitant dimeglumine EMEND VIAL    
fosnetupitant/palonosetron AKYNZEO VIAL    
granisetron HCl GRANISETRON HCL VIAL    
granisetron HCl/PF GRANISETRON HCL VIAL    
ondansetron HCl ONDANSETRON HCL VIAL    
ondansetron HCl/PF ONDANSETRON HCL AMPUL    
ondansetron HCl/PF ONDANSETRON HCL SYRINGE    
ondansetron HCl/PF ONDANSETRON HCL VIAL    
palonosetron HCl PALONOSETRON HCL SYRINGE    
palonosetron HCl PALONOSETRON HCL VIAL    
palonosetron HCl ALOXI VIAL