Antiemetics - BMC HealthNet Plan

Medication Name and StrengthAnzemet ®Emend ® 40mgEmend ® 80mgEmend ® 125mgEmend ® Pak (4-125mg and 8-80mg)granisetrongranisetron oral solutiondronabinolondansetron 4mg, 8mgondansetron 24mgondansetron ODTondansetron oral solutionSancuso ®Zuplenz ® 4mg, 8mgMaximum Quantity5 per 30 days1 per 30 days8 per 30 days4 per 30 days12 capsules (4 paks) per 30 days10 per 30 days50mL per 30 days30 per 30 days30 per 30 days5 per 30 days30 per 30 days75mL per 30 days4 patches per 30 days15 per 30 daysThis guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to BMCHealthNet Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All BMC HealthNet Plan policies are developed in accordance with state, federal andaccrediting organization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.8 of 10BMC HealthNet Plan – Antiemetics