Anzemet™ (granisetron)

Authorization forms

Anzemet tablets:

Medicare Part B vs. Part D determination (09/2019)

Anzemet solution:

Prior authorization required for home infusion providers only

Home Infusion Services authorization request

Code(s): J1260

Benefit: Medical

Notes: Per 10 mg, antiemetic. PA required for HINF provider ONLY.

Criteria for coverage: See PA form. May be covered under Medicare Part B or Part D depending on circumstances.