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
Physician-administered drugs are generally covered under Medicare Part B if (1) they are reasonable and necessary for the diagnosis or treatment of the illness or injury for which they are administered according to accepted standards of medical practice; (2) they are not usually self-administered; and (3) they meet the requirements for coverage of items as incident to a physician’s service. The general requirements for coverage under the “incident to” provision are that the drug be of a form that is not usually self-administered and that the drug be furnished and administered by a physician.1 Medicare has not issued a National Coverage Determination (NCD) for ALOXI®. Local Medicare contractors (Fiscal Intermediary [FI], Carrier or Part A/B Medicare Administrative Contractor [MAC]) may make coverage decisions for ALOXI®. Some local contractors have published Local Coverage Determinations (LCDs) and other coverage instruction through articles and bulletins that relate to ALOXI®. However, the absence of a published coverage policy does not mean that there is no coverage for ALOXI®.
For more information on Medicare coverage for ALOXI®, contact the Eisai Assistance Program at 1-866-61-EISAI or 1-866-61-34724.
Payor Reimbursement
Services paid under the Medicare Hospital Outpatient Prospective Payment System (OPPS) are assigned to an Ambulatory Payment Classification (APC) code. Each APC is linked to a payment amount that represents the total payment to the hospital. In addition, separate payments are made for some drugs, biologicals, and devices. ALOXI® is separately reimbursed by Medicare under the APC system at Average Sales Price (ASP) plus 4%, adjusted quarterly.2
Administration Services
Drug administration Current Procedural Terminology (CPT) codes are assigned to APCs according to their clinical and resource requirements. Several drug administration codes may map to a single APC. APCs for drug administration services are updated yearly by CMS. Drug administration CPT codes may not be paid separately when performed in conjunction with certain surgical procedures.
1. See the Medicare Benefits Policy Manual, Chapter 15, section 50 for further information.
2. Federal Register Vol. 76, No. 230. November 30, 2011. Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self- Referral; and Patient Notification Requirements in Provider Agreements. http://www.cms.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage. Accessed November 30, 2011.
