Does J1454 require prior authorization?

Yes, J1454 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J1454?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J1454`, Injection, fosnetupitant 235 mg and palonosetron 0.25 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For non-preferred product approval: documentation of a prior trial (adequate dose and duration) of a preferred NK1 RA or 5HT3 RA and documentation of minimal clinical response to that trial.
Alternatively, for non-preferred product approval: documentation of history of intolerance, contraindication, or adverse event to a preferred NK1 RA or 5HT3 RA, plus physician attestation that the same intolerance/contraindication/adverse event would not be expected with the requested non-preferred product.

Physician attestation (statement in medical record) supporting expectation of superior clinical response with non-preferred product (when trial/failure route used) or supporting that intolerance/contraindication to preferred product would not occur with non-preferred product.

Documentation that oral antiemetics are administered prior to the chemotherapy infusion (when coverage sought under this policy for oral agents) — evidence that medication was given 'at time of chemotherapy' not self-administered at home.

Documentation of the emetogenic risk of the chemotherapy regimen (High, Moderate, Low, Minimal) supporting the need for NK1 RA and/or 5HT3 RA and whether combination therapy is guideline-appropriate.

When coverage for NK1 RA or NK1/5HT3 combination for Moderate emetic risk is requested, documentation of one or more patient-specific risk factors for CINV (younger age <55, female sex, prior CINV, low/no alcohol use, history of motion sickness or morning sickness, high anxiety).

Key Coverage Criteria

Prevention of chemotherapy-induced nausea and vomiting (CINV) due to High Emetic Risk parenteral anticancer agents when an NK1 RA (e.g., Emend, Cinvanti, Varubi) is used in combination with a 5HT3 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when an NK1 RA is used in combination with a 5HT3 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Prevention of CINV due to High Emetic Risk parenteral anticancer agents when a 5HT3 RA (Aloxi, Kytril, Sustol, Zofran) is used in combination with an NK1 RA.
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used (standalone option for moderate risk).
Prevention of CINV due to Moderate Emetic Risk parenteral anticancer agents when a 5HT3 RA is used in combination with an NK1 RA and the patient has one or more CINV risk factors (younger age <55 years; female sex; previous history of chemotherapy-induced nausea/vomiting; little or no previous alcohol use; history of motion sickness or morning sickness during pregnancy; high anxiety).
Treatment of breakthrough nausea and/or vomiting due to anticancer agent(s) (5HT3 RAs listed as indicated for this scenario).

11 Active Policies

BCBSM-2099264-5FE36B7570, FOSNETUPITANT PALONOSETRON INJECTION: AKYNZEO (C9033) RETIRED AS OF 10/8/2020

BCBSMS-L-5-01-531-AFD3857255, Akynzeo (netupitant and palonosetron)

POINT32HEALTH-PMNG-14551, Akynzeo (netupitant/palonosetron)

MULTI

BCBSNJ-DRUGS-072-283AA8103D, Injectable Antiemetic Agents [Dolasetron (Anzemet), Granisetron (Kytril, Sustol), Ondansetron (Zofran), Palonosetron (Aloxi), Rolapitant (Varubi), Aprepitant (Cinvanti), Fosaprepitant (Emend), and Fosnetupitant/Palonosetron (Akynzeo), Amisulpride (Barhemsys)]

HEALTHNET_OR-HNOR-NETUPITANT-AND-PALONOSETRON-AKYNZEO-FOSNETUPITANT-AND-PA-089C904F43, Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV); CP.PMN.158

MODA-AKYNZEO-A2ECE282CE, Akynzeo (fosnetupitant/palonosetron)

UHC-POL-antiemetics-oncology, Antiemetics for Oncology

UMR-POL-UMR-antiemetics-oncology, Antiemetics for Oncology

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

SUREST-POL-SUREST-antiemetics-oncology, Antiemetics for Oncology

AETNA-CPB-0724, Antiemetic Therapy

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J1454, Injection, fosnetupitant 235 mg and palonosetron 0.25 mg