Medicare AdvantagePrior AuthMedium impact
Sustol® granisetron (Revised)
Humana·KY, SC · Oncology·Medicaid
Effective date
Jul 23, 2025
We identified it
Jul 2, 2026
Summary
Sustol® (granisetron) extended-release subcutaneous injection now requires prior authorization for Medicaid members in Kentucky and South Carolina, as well as Medicare beneficiaries. Coverage requires either failure of IV ondansetron/granisetron at FDA doses OR use for highly/moderately emetogenic chemotherapy without prior 5-HT3 antagonist failure. This is a pharmacy coverage policy effective July 23, 2025, with revision dated June 24, 2026.
Action Required
By July 23, 2025: Billing team must implement prior authorization requirement for all Sustol® (granisetron extended-release) claims for Medicaid (Kentucky and South Carolina) and Medicare members. Update billing system to route claims through prior auth workflow. Obtain prior auth documentation showing either: (1) failure/intolerance of IV ondansetron or IV granisetron at FDA-indicated doses, OR (2) medical necessity for HEC/MEC without prior 5-HT3 antagonist failure. Oncology providers must include chemotherapy emetogenic risk level (HEC or MEC) and relevant clinical history on prior auth requests. Claims submitted without prior authorization will be denied.