F-00194 - Forwardhealth Prior Authorization/preferred Drug List (Pa/pdl) For Antiemetics, Cannabinoids Page 2

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PRIOR AUTHORIZATION PREFERRED DRUG LIST (PA/PDL) FOR ANTIEMETICS, CANNABINOIDS
F-00194 (11/09)
®
SECTION III B — CLINICAL INFORMATION FOR MARINOL
AND CESAMET (Continued)
16. Is there a clinically significant drug interaction between another medication
the member is taking and ondansetron?
 Yes
 No
If yes, list the other medication the member is taking and describe the clinically significant
drug interaction in the space provided.
17. Has the member experienced a clinically significant adverse drug reaction while taking
ondansetron?
 Yes
 No
If yes, describe the clinically significant adverse drug reaction in the space provided.
®
18. Has the member experienced a treatment failure with Emend
for chemotherapy-
related nausea and vomiting?
 Yes
 No
®
19. Does the member have a medical condition(s) preventing the use of Emend
?
 Yes
 No
®
If yes, list the medical condition(s) that prevents the use of Emend
in the space provided.
20. Is there a clinically significant drug interaction between another medication the
®
member is taking and Emend
?
 Yes
 No
If yes, list the other medication the member is taking and describe the clinically significant
drug interaction in the space provided.
21. Has the member experienced a clinically significant adverse drug reaction while
®
taking Emend
?
 Yes
 No
If yes, describe the clinically significant adverse drug reaction in the space provided.
SECTION III C — CLINICAL INFORMATION FOR CESAMET ONLY (Complete Section III B and Section III C for requests for
Cesamet.)
®
22. Has the member experienced a treatment failure with Marinol
for chemotherapy-
related nausea and vomiting?
 Yes
 No
Continued

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