Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form



Approval Period

Prevention and treatment of nausea and vomiting associated with chemotherapy.

First approval: Six months

Renewals: Six months

Practitioner Exemptions

  • Oncologist (medical)
  • Oncologist (radiation)

Special Notes

  • None

Special Authority Request Forms

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.