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Cinvanti (aprepitant)

Policy Number: PH-0336

 

Intravenous

Last Review Date: 5/1/2018

Date of Origin: 11/21/2017

Dates Reviewed: 11/2017, 02/2018, 05/2018

 

  1. Length of Authorization

Coverage is provided for six months and may be renewed.

  1. Dosing Limits
  1. Quantity Limit (max daily dose) [Pharmacy Benefit]:
  • Cinvanti 130 mg vial injection: 4 vials per 28 days
  1. Max Units (per dose and over time) [Medical Benefit]:
  • 130 mg (billable units) on day 1 of chemotherapy per 7 days
  1. Initial Approval Criteria

Coverage is provided in the following conditions:

  • Patient is age of 18 years or older; AND

Prevention of Chemotherapy induced Nausea and vomiting (CINV) †

  • Patient is receiving highly and/or moderately emetogenic chemotherapy (see HEC/MEC list below); AND
  • Must be used in combination with a 5-HT3 antagonist such as ondansetron, granisetron, palonosetron, etc.; AND
  • Must be used in combination with a corticosteroid such as dexamethasone; AND
  • Patient is not taking pimozide concurrently

Highly Emetogenic Chemotherapy (HEC)

Carboplatin

Carmustine

Cisplatin

Cyclophosphamide

Dacarbazine

Doxorubicin

Epirubicin

Ifosfamide

Mechlorethamine

Streptozocin

Moderately Emetogenic Chemotherapy (MEC)

Aldesleukin

Amifostine

Arsenic Trioxide

Azacitidine

Bendamustine

Busulfan

Clofarabine

Cytarabine

Dactinomycin

Daunorubicin

Dinutuximab

Idarubicin

Interferon alfa

Irinotecan

Melphalan

Methotrexate

Oxaliplatin

Temozolomide

Trabectedin

Daunorubicin Liposomal; Cytarabine Liposomal

The following regimens can be considered HEC:

FOLFOX

FDA-approved indication(s)

  1. Renewal Criteria

Coverage can be renewed based upon the following criteria:

  • Patient continues to meet criteria identified in section III; AND
  • Disease response; AND
  • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: severe hypersensitivity reactions, neutropenia, dermatologic toxicity, etc.
  1. Dosage/Administration

Indication

Dose

Prevention of chemotherapy-induced nausea and vomiting

HEC (Single Dose Regimen)

  • 130 mg IV Day 1, given 30 minutes prior to chemo

MEC (3-Day Regimen with oral aprepitant)

  • 100 mg IV Day 1, given 30 minutes prior to chemo followed by oral apprepitant 80mg on Day 2-3.
  1. Billing Code/Availability Information

Jcode:

  • J0185 - Injection, aprepitant, 1 mg: 1 billable unit =  1 mg (effective 1/1/19)
  • J3490 – Unclassified drugs
  • C9463 – Injection, aprepitant, 1 mg  (Hospital Outpatient Use ONLY) (inactive 1/1/19)

NDC:

  • Cinvanti 130 mg/18 mL injectable emulsion vial: 47426-0201-xx
  1. References
  1. Cinvanti [package insert]. San Diego, CA; Heron Therapeutics; November 2017. Accessed March 2018.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Aprepitant. National Comprehensive Cancer Network, 2018. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc.” To view the most recent and complete version of the Compendium, go online to NCCN.org. March 2018.
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Antiemesis. Version 1.2018. National Comprehensive Cancer Network, 2018. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc.” To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed March 2018.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

R11.0

Nausea

R11.10

Vomiting, unspecified

R11.11

Vomiting without nausea

R11.12

Projectile vomiting

R11.2

Nausea with vomiting, unspecified

T45.1X5A

Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter

T45.1X5S

Adverse effect of antineoplastic and immunosuppressive drugs, sequela

T45.95XA

Adverse effect of unspecified primarily systemic and hematological agent, initial encounter

T50.905A

Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter

Z51.11

Encounter for antineoplastic chemotherapy

Z51.12

Encounter for antineoplastic immunotherapy

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD):

N/A

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA, HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC