Limited coverage criteria – netupitant-palonosetron

 

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Generic name	netupitant-palonosetron
Strength & form	300 mg/0.5 mg, capsule

Special Authority criteria	Approval period
For the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy in combination with dexamethasone	Up to a maximum number of standard, planned treatment cycles of highly emetogenic cancer chemotherapy (usually 6 or fewer treatment cycles), as specified in the relevant BC Cancer chemotherapy protocol Once-per-cycle treatment of highly-emetogenic cancer chemotherapy, administered orally on day 1 only as specified in the relevant BC Cancer chemotherapy protocol

Practitioner exemptions

• Oncologists and BC Cancer-designated oncology specialists  are invited to apply for individual specialist exemption from completing SA forms. See Collaborative Prescribing Agreement (CPA)

Special notes

• Highly emetogenic chemotherapy is defined by greater than 90% of patients experiencing emesis if not treated. Emetogenicity of chemotherapy is determined in accordance with the BC Cancer protocols for combination chemotherapy (see individual protocols for assessment of emetogenicity and SCNAUSEA supportive care protocol rating)
• Coverage is not intended for the prevention of nausea and vomiting with cancer chemotherapy of high-moderate, low-moderate, low- or rare-emetogenicity. However, exceptional case coverage requests may be submitted to PharmaCare
•  Exceptional case submissions are required for all patients who do not meet the above limited coverage criteria and from all physicians (including those with exemption under Collaborative Prescribing Agreement)

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 – General Special Authority request (PDF, 656KB)