Oral Anti-Emetic Medications

Section 4557 of the Balanced Budget Act of 1997 (BBA) extends the coverage of oral anti-emetic medications under the following conditions:

• Coverage is provided only for oral medications approved by the Food and Drug Administration (FDA) for use as anti-emetics
• Oral anti-emetic medications must either be administered by the treating physician or in accordance with a written order from the physician as part of a cancer chemotherapy regimen
• Oral anti-emetic medications administered with a particular chemotherapy treatment must be initiated within two hours of the administration of the chemotherapeutic medication and may be continued for a period not to exceed 48 hours from that time
• The oral anti-emetic medications provided must be used as full therapeutic replacement for the intravenous anti-emetic medications that would have otherwise been administered at the time of the chemotherapy treatment

Only medications prescribed pursuant to a physician's order at the time of chemotherapy treatment qualify. The dispensed number of dosage units may not exceed a loading dose administered within two hours of that treatment plus a supply of additional dosage units not to exceed 48 hours of therapy.

Oral medications that are not approved by the FDA for use as anti-emetics and that are used by treating physicians incidental to cancer chemotherapy are not covered or reimbursable.

A limited number of members will fail on oral anti-emetic medications. Intravenous anti-emetics may be covered (subject to medical necessity) when furnished to members who fail on oral anti-emetic therapy.