Coverage Policy
The information displayed below pertains specifically to the Physician Office setting of care. For information tailored to the Hospital Outpatient setting or Ambulatory Surgery Center setting please select the appropriate tab to the 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
Commercial payor reimbursement for ALOXI® may be based on a percent markup of 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).
Administration Services
Commercial payor reimbursement for physician-related ALOXI® drug administration services may be based on a common fee schedule similar to the Medicare reimbursement methodology for physician services or other contracted rates.
