Skip to main content

Call the helpline at 800-987-7767, option 5, and talk to choice counselors to change your SoonerSelect health plan!

Antiemetics

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Antiemetics

Drugs

Quantity Limits

Aloxi (Palonosetron HCL) 0.075mg/1.5ml Vial 

 4 Vials (6mls) per 28 days

Aloxi (Palonosetron HCL) 0.25mg/5ml Vial 

 4 Vials (20mls) per 28 days before chemotherapy

Anzemet (Dolasetron Mesylate)  50mg and 100mg Tablets 

 2 Tablets per day up to 5 days

Emend (Aprepitant) 125mg-80mg Convenience Pack Capsules

  2 packs per 30 days 

Emend (Aprepitant) 40mg, 80mg and 125mg Capsules

  1 pack per 30 days

Emend (Fosaprepitant Dimeglumine) 115mg Vial

 1 Vial per 30 days

Granisol (Granisetron) 1mg/5ml Solution

 30mls per 10 days

Kytril (Granisetron HCL) 1mg Tablets 

 2 Tablets per day up to 10 days

Sancuso (Granisetron Transderm)  3.1mg/24hr Patch

  1 Patch per 21 days

Zofran (Ondansetron HCL) 4mg, 8mg and 24mg Tablets 

 4mg and 8mg - 12 Tablets per 30 days                         24mg - 1 Tablet per 1 day in 30 day period

Zofran (Ondansetron HCL) 4mg/5ml Solution 

 50 Mls per 28 days

Zofran ODT (Ondansetron HCL) 4mg and 8mg Rapdis Tablets 

 12 Tablets per 30 days

 

Last Modified on Nov 17, 2020
Back to Top
Back to top

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

Contact Us

The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.