Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document. I. FDA Approved Indications: Granisetron Anzemet Anzemet Granisetron Sancuso Aloxi injection tablet & injection tablet injection patch Granisol Moderately emetogenic X cancer X Patient is chemotherapy X In adults receiving (MEC)- Also approved and chemotherapy prevention of for delayed X X children 2 regimens up acute nausea & nausea and years and to 5 vomiting vomiting older consecutive associated with days duration initial and repeat courses X Also indicated in pediatric patients aged 1 month to Highly less than 17 years emetogenic for prevention of X cancer acute nausea and Patient is chemotherapy vomiting receiving (HEC)- associated with chemotherapy prevention of initial and repeat X X regimens up acute nausea & courses of to 5 vomiting emetogenic consecutive associated with cancer days duration initial and chemotherapy, repeat courses. including highly emetogenic cancer chemotherapy

Prevention of nausea & vomiting X associated with radiation (RINV),

Draft Prepared: December 17, 2002 1 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Granisetron Anzemet Anzemet Granisetron Sancuso Aloxi injection tablet & injection tablet injection patch Granisol including total body irradiation and fractionated abdominal radiation X Used for up to X Prevention of 24 hours In adults postoperative following and nausea and surgery. X children 2 vomiting Efficacy beyond years and (PONV). 24 hours has older not been demonstrated X Treatment of In adults postoperative and nausea and X children 2 vomiting years and (PONV) older

II. Health Net Approved Indications and Usage Guidelines: Prevention of nausea and vomiting associated with cancer chemotherapy for Anzemet tablet, Granisetron injection and tablet, Granisol and Sancuso patch: • Patient has received, or will receive, highly or moderately emetogenic chemotherapy AND • Failure or clinically significant adverse events to ondansetron or Aloxi

Prevention of nausea and vomiting associated with radiation therapy (RINV) for Granisetron tablet and Granisol: • Patient will receive radiation therapy AND • Failure or clinically significant adverse events to ondansetron

Prevention of postoperative nausea and vomiting (PONV) for Aloxi, Anzemet injection and Granisetron injection: • Patient is undergoing surgery AND

Draft Prepared: December 17, 2002 2 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

• Failure or clinically significant adverse events to ondansetron

Treatment of PONV for Anzemet injection and Granisetron injection: • Patient underwent surgery

AND

• 5-HT 3 antagonist was not used for prevention of PONV

III. Coverage is Not Authorized For: • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section unless there is sufficient documentation of efficacy and safety in the published literature. • Anzemet injection solution is contraindicated in adult and pediatric patients for the prevention of nausea and vomiting associated with the initial and repeat courses of emetogenic cancer chemotherapy

IV. General Information: • The NCCN Antiemesis guidelines Version 1.2012 added Aloxi as the preferred 5HT-3 antagonist for highly or moderately emetogenic chemotherapy • Anzemet injection solution prolongs the QT interval in a dose dependent fashion. Torsades de Pointes has been reported during post-marketing experience. Avoid Anzemet in patients with congenital long QT syndrome, hypokalemia or hypomagnesemia. • Anzemet injection solution administered intravenously is contraindicated in adult and pediatric patients for the prevention of nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy due to dose dependent QT prolongation. • When prophylaxis has failed using Anezemt injection, a repeat dose should not be initiated as rescue therapy. • Serotonin subtype 3 (5-HT3) receptor antagonist may cause serotonin syndrome alone but particularly with concomitant use of serotonergic drugs. • According to the 2011 American Society of Clinical Oncology (ASCO) Guideline for Antiemetics in Oncology, the Update Committee recommends the following: • For chemotherapy of high emetic risk - three-drug combination of 5-hydroxytryptamine-3 (5-HT3) serotonin receptor antagonist, dexamethasone, and aprepitant. The oral combination of netupitant and palonosetron plus dexamethasone is an additional treatment option in this setting. For chemotherapy of moderate emetic risk - two-drug combination of a 5-HT3 serotonin receptor antagonist and dexamethasone • Per practice guidelines from the National Comprehensive Cancer Network (NCCN), selection of emetogenic agents used should be based on the emetic risk of the therapy, prior experience with antiemetics, as well as patient risk factors. • The following table is NCCN’s classification for emetogenic potential of significant chemotherapy and other agents.

Draft Prepared: December 17, 2002 3 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Agents Frequency of Emesis AC combination defined as either doxorubicin or epirubicin with cyclophosphamide, carmustine > 250 mg/m 2, cisplatin, 2 High Emetic Risk cyclophosphamide > 1,500 mg/m , doxorubicin ≥ 60mg/m², epirubicin >90% >90mg/m², ifosfamide ≥ 2gm/m² per dose, dacarbazine, mechlorethamine, streptozocin aldesleukin > 12-15 million IU/m 2, amifostine > 300 mg/m 2, arsenic trioxide, azacitidine, bendamustine, busulfan, carboplatin, carmustine ≤ 250 mg/m 2, , clofarabine, cyclophosphamide ≤ 1500 mg/m 2, cytarabine Moderate Emetic Risk > 200mg/m 2, dactinomycin, daunorubicin, doxorubicin < 60 mg/m2, 30-90% epirubicin ≤ 90mg/m², idarubicin, ifosfamide < 2gm/m² per dose, interferon alpha ≥ 10 million IU/m 2, irinotecan, melphalan, MTX ≥ 250 mg/m 2, oxaliplatin, temozolomide ado-trastuzumab emtansine, amifostine ≤ 300 mg, aldesleukin ≤ 12 million IU/m 2, brentuximab vedotin,cabazitaxel, carfilzomib, cytarabine (low dose) 100 - 200 mg/m 2, docetaxel, doxorubicin (liposomal), eribulin,etoposide, 5-fluorouracil, floxuridine, gemcitabine, interferon Low Emetic Risk alpha > 5 <10 million IU/m 2, ixabepilone, MTX > 50 mg/m 2 < 250 10-30% mg/m 2, mitomcyin, mitoxantrone, omacetaxine,paclitaxel, paclitaxel- albumin, pemetrexed, pentostatin,pralatrexate, romidepsin, thiotepa, topotecan, ziv-aflibercept alemtuzumab, asparaginase, bevacizumab, bleomycin, bortezomib, cetuximab, 2-chlorodeoxyadenosine (cladribine), cytarabine < 100mg/m 2, decitabine, denileukin diftitox, dexrazoxane, fludarabine, , Minimal Emetic Risk interferon alpha ≤ 5 million IU/m 2, ipilimumab, MTX ≤ 50 mg/m 2, <10% nelarabine, ofatumumab, panitumumab, pegaspargase,peginterferon, pertuzumab, rituximab, temsirolimus, trastuzumab, valrubicin, vinblastine, vincristine, vincristine (liposomal), vinorelbine altretamine, busulfan ( ≥ 4 mg/d), crizotinib, cyclophosphamide ( ≥ 100 Emetogenic potential of mg/m 2/d), estramustine, etoposide, lomustine (single day), mitotane, oral antineoplastic procarbazine, temozolomide (> 75 mg/m 2/d), vismodegib agents: Moderate to High axitinib,bexarotene, bosutinib, busulfan (< 4 mg/d), cabozantinib, capecitabine, chlorambucil, cyclophosphamide (< 100 mg/m 2/d), dasatinib,dabrafenib, erlotinib, everolimus, fludarabine, gefitinib, Emetogenic potential of hydroxyurea, imatinib, lapatinib, lenalidomide, melphalan, oral antineoplastic mercaptopurine, methotrexate, nilotinib, pazopanib, pomalidomide, agents: Minimal to low ponatinib, regorafenib, ruxolitinib,sorafenib, sunitinib, temozolomide ( ≤ 75 mg/m 2/d), thalidomide, thioguanine, topotecan,trametinib, tretinoin, vandetanib, vemurafenib, vorinostat

V. Therapeutic Alternatives:

Draft Prepared: December 17, 2002 4 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Drug Dosing Regimen Dosing Limit/Maximum Dose 5-HT3 serotonin MEC: As specified by length receptor Adults and children 12 years and older: 8 mg PO of chemotherapy antagonist BID administered 30 minutes before the start of ondansetron chemotherapy, with a subsequent dose 8 hours (Zofran )* after the first dose; continue 8 mg PO BID for 1 to 2 days after completion of chemotherapy.

Adults: Three 0.15 mg/kg IV doses up to a maximum of 16 mg per dose. The first dose is infused over 15 minutes beginning 30 minutes before the start of chemotherapy and subsequent doses are administered 4 and 8 hours after the first dose

Children 4-11 years: 4 mg PO TID administered 30 minutes before the start of chemotherapy, with subsequent doses 4 and 8 hours after the first dose; continue 4 mg PO TID for 1 to 2 days after completion of chemotherapy.

Children 6 months-18 years: Three 0.15 mg/kg doses IV doses administered 30 minutes before the start of chemotherapy, with subsequent doses 4 and 8 hours after the first dose. Each dose is infused over 15 minutes. HEC: Adults: 24 mg (given as three 8 mg tablets) PO administered 30 minutes before the start of single- day chemotherapy.

Adults: Three 0.15 mg/kg IV doses up to a maximum of 16 mg per dose. The first dose is infused over 15 minutes beginning 30 minutes before the start of chemotherapy and subsequent doses are administered 4 and 8 hours after the first dose.

Children 6 months-18 years: Three 0.15 mg/kg doses IV doses administered 30 minutes before the start of chemotherapy, with subsequent doses 4 and 8 hours after the first dose. Each dose is infused over 15 minutes.

Draft Prepared: December 17, 2002 5 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Drug Dosing Regimen Dosing Limit/Maximum Dose RINV: As specified by Total body irradiation: Adults: 8 mg PO given 1 to 2 prescriber hours before each fraction of radiotherapy administered each day. Maximum 8 mg PO TID for up to 3 days Single high dose fraction radiotherapy to the per cycle. abdomen: Adults: 8 mg PO given 1 to 2 hours before radiotherapy, with subsequent doses every 8 hours after the first dose; continue 1 to 2 days after completion of radiotherapy.

Daily fractionated radiotherapy to the abdomen: Adults: 8 mg PO given 1 to 2 hours before radiotherapy, with subsequent doses every 8 hours after the first dose for each day radiation is given Prevention of PONV: Prevention of Adults: 16 mg (given as two 8 mg tablets) PO 1 hour postoperative nausea before induction of anesthesia and vomiting: One day Adults: 4 mg undiluted IV infused over 2 to 5 minutes before induction of anesthesia

Children 1 month–12 years: 0.1 mg/kg IV dose (for patients weighing 40 kg or less) or 4 mg IV dose (for patients weighing more than 40 kg) infused over 2 to 5 minutes before induction of anesthesia substance MEC and HEC: 1 x 125 mg capsule P/neurokinin 1 125 mg PO 1 hour prior to chemotherapy and 80 mg (or 1 x 115 mg IV) and (NK1) receptor on Day 2, 3 2 x 80 mg capsules antagonist per cycle Emend  Emend 115 mg IV may be substituted for Emend (aprepitant) 125 mg PO 30 minutes prior to chemotherapy on day 1 only if the CINV regimen as an infusion administered over 15 minutes. Prevention of PONV: 40 mg PO within 3 hours prior to induction of One day anesthesia Corticosteroid 20 mg PO (pre-chemotherapy) and 8 mg PO daily Dexamethasone on Day 2, 3 40mg/day (Decardron ®) Various chemotherapy dosage regimens Phenothiazine 100 mg/day

Draft Prepared: December 17, 2002 6 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Drug Dosing Regimen Dosing Limit/Maximum Dose Promethazine Oral, Rectal, IM: 12.5 mg-25 mg q4-6 hours prn (Phenergan )

Phenothiazine Oral: 5-10 mg PO q 6-8 hours. Prochlorperazine Rectal: 25 mg q12 hours 40 mg PO/day (Compazine ) IM: 5-10 mg initially, repeat q 3-4 hours prn Benzodiazepine 0.5-2 mg PO or IV q 4-6 hours prn Lorazepam Various chemotherapy dosage regimens 10 mg/day (Ativan ) *Requires prior authorization

VI. Recommended Dosing Regimen and Authorization Limit: Drug Dosing Regimen Authorization Limit Aloxi MEC and HEC: Length of benefit

Adults: 0.25 mg IV infused over 30 seconds beginning 30 minutes prior to chemotherapy.

Pediatrics (1 month to less than 17 years): 20 mcg/kg (max 1.5 mg) infused over 15 minutes beginning 30 minutes prior to chemotherapy. Prevention of PONV: Prevention of Adults: 0.075 mg IV infused over 10 seconds postoperative nausea and immediately before the induction of the vomiting: One day anesthesia

Efficacy beyond 24 hours has not been demonstrated. Anzemet Prevention of cancer chemotherapy induced Length of benefit nausea and vomiting Adults: 100 mg PO given within 1 hour prior to chemotherapy.

Children 2-16 years: 1.8 mg/kg up to a maximum of 100 mg PO given within 1 hour prior to chemotherapy

Safety and effectiveness in pediatric patients under 2 years of age have not been established. Prevention or treatment of PONV: One day

Draft Prepared: December 17, 2002 7 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Drug Dosing Regimen Authorization Limit Adults: 12.5 mg IV 15 minutes prior to cessation of anesthesia (prevention) or as soon as nausea or vomiting presents (treatment).

Children 2-16 years: 0.35 mg/kg up to a maximum of 12.5 mg IV given as a single dose approximately 15 minutes before the cessation of anesthesia or as soon as nausea or vomiting presents. The injection may also be given as an oral administration mixed in apple juice as 1.2 mg/kg up to a maximum 100 mg dose given within two hours before surgery.

Safety and effectiveness in pediatric patients under 2 years of age have not been established. Granisetron, MEC and HEC: Length of benefit Granisol Adults: 2 mg QD PO 1 hour prior to chemotherapy OR 1 mg BID PO 1 hour prior to chemotherapy and then 12 hours later

Adults: 10 mcg/kg IV infused over 30 seconds beginning 30 minutes prior to chemotherapy

Children 2-16 years: 10 mcg/kg IV prior to chemotherapy

Safety and effectiveness in pediatric patients under 2 years of age has not been established. Prevention of PONV: Postoperative nausea Adults: 1 mg IV infused over 30 seconds prior to and vomiting: One day induction of anesthesia or immediately before reversal of anesthesia.

Treatment of PONV: Adults: 1 mg administered IV over 30 seconds RINV: Length of benefit Adults: 2 mg PO QD within 1 hour of radiation Maximum 2 mg per day on days of radiation Sancuso MEC and HEC: Length of benefit Adults: Apply a single patch to the upper outer

Draft Prepared: December 17, 2002 8 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

Drug Dosing Regimen Authorization Limit arm from 24 to 48 hours before chemotherapy. Remove the patch a minimum of 24 hours after completion of chemotherapy.

The patch can be worn for up to 7 days depending on the duration of chemotherapy regimen.

VII. Product Availability: Aloxi: 0.25 mg/5 ml (single-use 5 ml vial), 0.075 mg/1.5 ml (single-use 1.5 ml vial) Anzemet: 50 mg, 100 mg tablets Anzemet: 12.5 mg/ 0.625 ml single use vial Anzemet: 100 mg/5 ml (single-use 5 ml vial) and 500 mg/25 ml (multidose 25 ml vial) Granisetron: 1 mg tablets Granisetron: 1 mg/ml (single-use 1 ml vial, multidose 4 ml vial) and 0.1 mg/ml (single-use 1 ml vial) Granisol 2 mg/10 mL oral solution 30 mL bottle Sancuso: 3.1 mg/24 hours transdermal patch

VIII. References: 1. Aloxi [package insert].Switzerland:Helsinn Healthcare; September 2014. 2. Anzemet Tablets [package insert] Bridgewater, NJ: Sanofi-Aventis; September, 2014. 3. Anzemet Injection[package insert] Bridgewater, NJ: Sanofi-Aventis; September, 2014. 4. Granisol ™ Injection [package insert] Sellersville, PA: Teva August 2014. 5. Granisol ™Tablets [package insert] Sellersville, PA: Teva August 2014 6. Sancuso Transdermal System [package insert] Bedminster, NJ: ProStrakan;September 2015. 7. Zofran Injection [package insert] Research Triangle Park, NC: GlaxoSmithKline September 2014. 8. Zofran Tablet/ODT/Oral Solution [package insert] Research Triangle Park,NC: GlaxoSmithKline September 2014.. 9. Emend capsules [package insert] Whitehouse Station, NJ: Merck December 2012. 10. Emend injection [package insert] Whitehouse Station, NJ: Merck December 2012.

11. ASHP Therapeutic Guidelines on the Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving Chemotherapy or Radiation Therapy or undergoing Surgery. Am J Health Syst Pharm.1999;56:730-764. 12. Gan TJ, Diemunsch, P, Habib AS, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2014;118:85-113. 13. Basch E, Prestrud AA, Hesketh, PJ, et al. Antiemetics: American Society of Clinical Oncology (ASCO) Clinical Practice Guideline Update 2011 J Clin Oncol 29:4189-4198 .

Draft Prepared: December 17, 2002 9 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero

Prior Authorization Protocol    ALOXI  (palonosetron), ANZEMET  (dolasetron), SANCUSO , GRANISOL ™ (granisetron)

NATL

14. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology - Antiemesis Version 1.2012. NCCN Web site. Available at: http://www.nccn.org/. Accessed July 7, 2014. 15. Aloxi. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 21, 2015. 16. Anzemet. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 21, 2015. 17. Granisetron. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 21, 2015. 18. Micromedex ® Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed February 10, 2016 19. Antiemetics: American Society of Clinical Oncology Focused Guideline Update. Available at: http://www.instituteforquality.org/antiemetics-asco-clinical-practice-guideline-update . Accessed February 10, 2016

The material provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Draft Prepared: December 17, 2002 10 Approved by Health Net Pharmacy and Therapeutics Committee: 4.11.06, 5.16.07, 05.21.08, 11.18.09, 11.17.10, 11.9.11, 11.14.12, 11.20.13, 11.19.14, 11.18.15 Updated: 10.17.03, 1.24.05, 12.07.05 RJL, 01.02.06 JP, 02.06.06 RJL, 02.27.06 RJL, 08.18.06 RO, 04.03.07 RO, 9.20.07 RO, 1.04.08 RO, 08.08.08 RO, 08.01.09 R Olegario, 10.26.10 R Olegario, 06.07.11 A Giordano, 7.12.12 R. Gedey, 07.11.13 MJMcClusky,07.07.14 S Mirando, 06.19.15 T You02.10S Ahantab, 12.15.16 M Del Nero