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
ALOXI® is eligible for coverage under most state Medicaid programs. However, coverage and reimbursement will vary from state to state as each Medicaid program establishes its own eligibility standards and determines the type, amount, duration, and scope of services. Reimbursement rates for services will also vary from state to state. Some Medicaid programs may cover ALOXI® as a medical benefit, pharmacy benefit, or both. In addition, state Medicaid programs may apply coverage and utilization restrictions such as prior authorization or step therapy.
For more information on Medicaid-specific coverage for ALOXI®, contact the Eisai Assistance Program at 1-866-61-EISAI or 1-866-61-34724.
Payor Reimbursement
Medicaid reimbursement for ALOXI® administered in the physician office setting varies by state Medicaid program. Some Medicaid programs may base reimbursement on ASP plus 4%. Others may base reimbursement on a percent markup or markdown of Average Wholesale Price (AWP) or Wholesale Acquisition Cost (WAC). Drug reimbursement rates may be updated by state Medicaid programs on a monthly, quarterly, or yearly basis.
Administration Services
Medicaid reimbursement for ALOXI® drug administration services provided in the physician office setting varies by state Medicaid program. Many states base reimbursement on a statewide fee schedule that may be updated on a quarterly or annual basis.
