Prior Authorization Approval Criteria Zofran (ondansetron) Generic Name: ondansetron Brand Name: Zofran Medication Class: 5HT3 antiemetic FDA Approved Uses: -Prevention of nausea and vomiting associated with emetogentic cancer chemotherapy. -Prevention of nausea and vomiting associated with radiotherapy in patients receiving either total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen. -Postoperative nausea and vomiting; Prophylaxis. Other Uses: -Hyperemesis gravidarum Usual Doses: -Prevention of nausea and vomiting associated with chemotherapy or radiation therapy:8 mg every 8 hours for 1-2 doses beginning 30 minutes prior to chemotherapy or 1-2 hours prior to radiation therapy followed by 8 mg every 12-24 hours for 1-2 days after chemotherapy or radiation therapy. - Postoperative nausea and vomiting: 8-16mg 1 hour prior to surgery -Hyperemesis gravidarum: Determined by prescriber. Duration of Therapy: -Prevention of nausea and vomiting associated with chemotherapy or radiation therapy: 3days total - Postoperative nausea and vomiting: 1 day -Hyperemesis gravidarum: Up to the duration of pregnancy Criteria for Use: (bullet points below are all inclusive unless otherwise noted) Prevention of postoperative nausea and/or vomiting. Allowed for 1 dose 1 hour before induction of anesthesia Or Patient has tried approved dosing (30 tablets (4mg or 8mg) or 45ml per month) and it is insufficient to control nausea and vomiting. Patient has one of the following conditions: Nausea and vomiting due to chemotherapeutic agents. Nausea and vomiting due to total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen. Use in pregnant woman who have failed conventional antiemetic therapy (ie. promethazine, prochlorperazine and metoclopramide) and are at risk of dehydration and require IV fluids. Allowed for only 1 month at a time. Page 1 of 2 11/19/04 Revised 1/13/13 Revised 11/15/13 Criteria for continuation of therapy in pregnancy: (bullet points below are all inclusive unless otherwise noted) Patient is tolerating and responding to medication and there continues to be a medical need for the medication. Only approved for 1 month at a time Not approved if: Nausea and vomiting is due to a GI viral illness. Chronic use of an antiemetic is needed, without a clinically defined etiology. Notes: No PA required for up to 30 tablets (4mg or 8mg) or 45ml per month Doses could be tablets or oral solution P&T Approval: ___________________________________________ Date: _________________ Page 2 of 2 11/19/04 Revised 1/13/13 Revised 11/15/13 .