sign in sign up
<<
Home , Dronabinol

Cigna National Formulary Coverage Policy

Prior Authorization Dronabinol - Marinol® (dronabinol capsules), Syndros® (dronabinol oral solution)

Table of Contents Product Identifer(s)

National Formulary Medical Necessity ...... 1 60204 Conditions Not Covered...... 2 Background ...... 3 References ...... 3 Revision History ...... 4

INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

National Formulary Medical Necessity

Cigna covers Dronabinol products (Marinol®, Syndros®) as medically necessary when the following criteria are met for FDA Indications or Other Uses with Supportive Evidence:

Prior authorization is recommended for prescription benefit coverage of dronabinol due to the potential for off- label use of dronabinol. All approvals are provided for the duration noted below. In cases where the approval is authorized in months, 1 month is equal to 30 days.

A. Coverage of dronabinol capsules is recommended in those who meet the following criteria:

FDA Indication(s)

1. Associated with Weight Loss in Individuals with Acquired Immune Deficiency Syndrome (AIDS): Approve for 6 months if ONE of the following criteria is met (A or B): A) Generic dronabinol capsules are requested; OR B) If brand Marinol is prescribed, the individual has tried generic dronabinol capsules AND the Brand product is being requested due to a formulation difference in the inactive ingredient(s) [e.g., difference in

Page 1 of 4 Cigna National Formulary Coverage Policy: PA Dronabinol – Marinol, Syndros dyes, fillers, preservatives] between the Brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction.

2. Nausea and Vomiting Associated with Cancer Chemotherapy in Individuals who have Failed to Respond Adequately to Conventional Treatments: Approve for 1 year if the individual meets BOTH of the following criteria (A and B): A) Individual has failed to respond adequately to at least two conventional antiemetic treatments; AND Note: Examples of conventional antiemetic treatments include selective serotonin [5-HT3] receptor antagonists [such as , , Anzemet® {dolasetron}, Aloxi® { injection}], Akynzeo® [/palonosetron capsules], Emend® ( capsules), Varubi™ ( tablets), , prochlorperazine, . B) Individual meets ONE of the following criteria (i or ii): i. Generic dronabinol capsules are requested; OR ii. If brand Marinol is prescribed, the individual has tried generic dronabinol capsules AND the Brand product is being requested due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction.

B. Coverage of Syndros is recommended in those who meet the following criteria:

FDA-Approved Indications

1. Anorexia Associated with Weight Loss in Individuals with Acquired Immune Deficiency Syndrome (AIDS): Approve Syndros for 6 months if the individual meets ONE of the following criteria (A or B): A) Individual has tried generic dronabinol capsules; OR B) Individual cannot swallow or has difficulty swallowing capsules.

2. Nausea and Vomiting Associated with Cancer Chemotherapy in Individuals who have Failed to Respond Adequately to Conventional Antiemetic Treatments: Approve Syndros for 1 year if the individual meets BOTH of the following criteria (A and B): A) Individual has failed to respond adequately to at least two conventional antiemetic treatments; AND Note: Examples of conventional antiemetic treatments include selective serotonin [5-HT3] receptor antagonists [such as ondansetron, granisetron, Anzemet® {dolasetron}, Aloxi® {palonosetron injection}], Akynzeo® [netupitant/palonosetron capsules], Emend® (aprepitant capsules), Varubi™ (rolapitant tablets), metoclopramide, prochlorperazine, dexamethasone. B) Individual meets ONE of the following (i or ii): i. Individual has tried generic dronabinol capsules; OR ii. Individual cannot swallow or has difficulty swallowing capsules.

Conditions Not Covered

Dronabinol (Marinol®, Syndros®) is considered experimental, investigational or unproven for ANY other use including the following (this list may not be all inclusive):

1. Chronic Non-Cancer Pain. Based on a review of published studies, there is insufficient evidence for the use of dronabinol in non-cancer pain due to the small study sizes and moderate to high risk of bias to allow for a definitive conclusion.5 In the two studies reviewed, the authors reported mixed effects for pain measures for dronabinol. More data are needed to define the place in therapy of dronabinol in the treatment of chronic non-cancer pain.

2. Multiple Sclerosis. Results from one published, randomized, double-blind, placebo-controlled study (n = 498) demonstrated that dronabinol has no overall effect on the progression of multiple sclerosis in individuals with primary and secondary progressive multiple sclerosis.6 There is limited published evidence for the use of dronabinol in spasticity and pain in multiple sclerosis.7-8 An analysis of three studies in individuals with spasticity due to multiple sclerosis found some improvement with dronabinol vs. placebo, but it did not reach statistical significance.7 A small study (n = 24) in individuals with pain due to multiple

Page 2 of 4 Cigna National Formulary Coverage Policy: PA Dronabinol – Marinol, Syndros sclerosis found that dronabinol had a modest effect, but adverse effects were also more frequent with dronabinol over placebo.8 A study in individuals with multiple sclerosis and central (n = 240) found no difference between dronabinol and placebo in pain intensity.9 More data are needed to define the place in therapy of dronabinol in the treatment of multiple sclerosis.

3. Tourette’s syndrome. Published studies of dronabinol in individuals with Tourette’s syndrome are lacking.10 More data are needed to define the place in therapy of dronabinol in the treatment of Tourette’s syndrome.

Background

Overview Dronabinol capsules (Marinol®, generics) and Syndros® (dronabinol oral solution) are both indicated for anorexia associated with weight loss in individuals with Acquired Immune Deficiency Syndrome (AIDS) and for nausea and vomiting associated with cancer chemotherapy in individuals who have failed to respond adequately to conventional antiemetic treatments.1,2

Dronabinol is an orally active which has complex effects on the central nervous system (CNS).1,2 The active ingredient is synthetic delta-9- (delta-9-THC), which is a naturally occurring component of sativa L. (e.g., marijuana). Dronabinol demonstrates reversible effects on appetite, mood, cognition, memory, and perception. These effects appear to be dose-related, increasing in frequency with higher dosages, and subject to great interindividual variability. Dronabinol capsules have not been studied in and are not recommended for pediatric individuals with AIDS-related anorexia; caution is recommended in prescribing dronabinol capsules for children because of the psychoactive effects. The safety and effectiveness of Syndros have not been established in pediatric individuals. Dronabinol is a controlled substance; the capsules are CIII and the oral solution is CII.

In addition to the FDA-approved uses for dronabinol, several Phase III studies have been completed or are underway according to clinicaltrials.gov; the disease states being studied include anorexia nervosa, chronic pain, multiple sclerosis, and dependence.3 Published studies supporting these off-label uses are lacking.

Guidelines The National Comprehensive Cancer Network (NCCN) guidelines regarding the treatment of emesis (version 2.2020 – April 23, 2020) include various regimens depending upon the emetogenic potential of the chemotherapy agent(s) being administered.4 Dronabinol is included in the list of medications for breakthrough nausea or emesis. Other recommended agents for breakthrough nausea or emesis include serotonin 5-HT3 receptor antagonists, olanzapine, , , metoclopramide, , prochlorperazine, , and dexamethasone. The agent should be from a different drug class to the current regimen, but no preference is given.

Safety Dronabinol capsules contain sesame oil and are contraindicated in individuals who are allergic to this substance.1 Syndros is contraindicated in individuals with a history of hypersensitivity to alcohol and individuals who are receiving, or have recently received, disulfiram- or metronidazole-containing products within 14 days.2 Syndros contains 50% (w/w) dehydrated alcohol and 5.5% (w/w) propylene glycol.

References

1. Marinol® [prescribing information]. North Chicago, IL: AbbVie Inc.; August 2017. 2. Syndros® oral solution [prescribing information]. Chandler, AZ: , Inc.; September 2018. 3. US National Institutes of Health. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000- [cited 2020 October 13]. Available from: https://www.clinicaltrials.gov/. Accessed on October 13, 2020. Search term: dronabinol.

Page 3 of 4 Cigna National Formulary Coverage Policy: PA Dronabinol – Marinol, Syndros 4. The NCCN Clinical Practice Guidelines in Oncology for Antiemesis (Version 2.2020 – April 23, 2020). © 2020 National Comprehensive Cancer Network, Inc. Available at: www.nccn.org. Accessed on October 13, 2020. 5. Butler M, Krebs E, Sunderlin B, Kane R. for non-cancer pain: a systematic review. (Prepared by Minnesota Evidence-based Practice Center.) 2016. Available at: https://www.health.state.mn.us/people/cannabis/docs/intractable/medicalcannabisreport.pdf. Accessed on October 13, 2020. 6. Zajicek J, Ball S, Wright D, et al. Effect of dronabinol on progression in progressive multiple sclerosis (CUPID): a randomised, placebo-controlled trial. Lancet Neurol. 2013;12(9):857-865. 7. Whiting PF, Wolff RF, Deshpande S, et al. for medical use: a systematic review and meta- analysis. JAMA. 2015;313(24):2456-2473. 8. Svendsen KB, Jensen TS, Bach FW. Does the cannabinoid dronabinol reduce central pain in multiple sclerosis? Randomized double blind placebo controlled crossover trial. BMJ. 2004 Jul 31;329(7460):253. 9. Schimrigk S, Marziniak M, Neubauer C, et al. Dronabinol is a safe long-term treatment option for neuropathic pain individuals. Eur Neurol. 2017;78(5-6):320-329. 10. Muller-Vahl KR. Treatment of Tourette syndrome with cannabinoids. Behavioral Neurol. 2013;27:119-124.

Revision History

Type of Summary of Changes Approval Date Revision Annual Nausea and Vomiting Associated with Cancer Chemotherapy in Individuals 10/21/2020 Revision who have Failed to Respond Adequately to Conventional Antiemetic Treatments: Moved examples of to a note. Prescribing physician was changed to prescriber as needed throughout the criteria.

“Cigna Companies” refers to operating subsidiaries of Cigna Corporation. All products and services are provided exclusively by or through such operating subsidiaries, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., QualCare, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2021 Cigna.

Page 4 of 4 Cigna National Formulary Coverage Policy: PA Dronabinol – Marinol, Syndros