Coverage Policy
The information displayed below pertains specifically to the Hospital Outpatient setting of care. For information tailored to the Physician Office setting or Ambulatory Surgery Center setting, please select the appropriate tab to the left or right. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Most third-party payors, including health maintenance organization (HMO) plans, managed care organizations, indemnity plans and others provide coverage for ALOXI®. However, specific coverage requirements and restrictions depend on a patient’s benefits and will vary based on plan type and provider site of service. Some payors have established formal published policies, but the lack of a published policy from a particular payor does not mean that ALOXI® is not covered by that payor. Some commercial insurers may apply coverage and utilization restrictions such as prior authorization or step therapy.
For more information on commercial payor-specific coverage for ALOXI®, contact the Eisai Assistance Program at 1-866-61-EISAI or 1-866-61-34724.
Payor Reimbursement
Reimbursement for ALOXI® may be based on a percent markup of Average Sales Price (ASP) similar to Medicare reimbursement methodologies. Payment may also be based on a percent markup or markdown of Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC) or facility-specific cost-to-charge ratios.
Administration Services
Reimbursement for ALOXI® drug administration services provided in the hospital outpatient setting may be based on a common fee schedule similar to the Medicare reimbursement methodology for physician services, facility-specific cost-to-charge ratios, per diem methodologies or other contracted rates.
