Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article

Oral antiemetic drugs are covered when FDA‑approved as antiemetics, ordered by the treating practitioner as part of a cancer chemotherapy regimen, used as a full therapeutic replacement for an IV antiemetic that would otherwise be given at the time of chemotherapy, and initiated within two hours of chemotherapy and continued no more than 48 hours (24 hours for granisetron and dolasetron). Specific 3‑drug regimens (NK‑1 + 5HT3 + dexamethasone) and netupitant/palonosetron with dexamethasone are covered when these criteria are met; quantities are limited to the initial loading dose plus the permitted post‑chemotherapy hours and dispensing is limited to a 30‑day supply with specific supply‑fee billing rules. Required documentation includes a written signed and dated order prior to claim submission, cancer diagnosis codes (and chemotherapy encounter codes for certain agents), appropriate modifiers (KX/GA/GZ), and compliance with Final Rule 1713 face‑to‑face and WOPD requirements for specified HCPCS codes.