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PHARMACY PRE-AUTHORIZATION CRITERIA DRUG (S) Cesamet (nabilone) POLICY # 14153 INDICATIONS Cesamet capsules are indicated for the treatment of the nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments. CRITERIA ConnectiCare considers Cesamet to be medically necessary for patients who meet all of the following criteria: • Patient is being treated for nausea and vomiting associated with cancer chemotherapy • Patient has an intolerance to, or treatment failure of at least two previous antiemetic therapies, one of which must be a serotonin 5HT 3 antagonist (i.e. Zofran) LIMITATIONS If the above criteria are met prior authorization will be given for an initial 3 months. All subsequent approvals will be granted for 3 months at a time. The quantity is limited to the appropriate amount required for the patient’s chemotherapy cycle. REFERENCES Cesamet prescribing information Valeant Pharmaceuticals International Costa Mesa, CA P&T REVIEW HISTORY 6/07, 6/08, 9/09, 9/10, 12/11, 10/12, 10/13, 10/14, 11/15, 11/16 REVISION RECORD
