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
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
Medicare Part B reimbursement for ALOXI® in the physician office setting is based on Average Sales Price (ASP). Medicare sets an allowable payment amount, updated quarterly, at ASP plus 6%. Medicare reimbursement is based on the lesser of this allowable amount or actual charges, as follows: physician offices are reimbursed for 80% of the allowable amount, and the patient or patient's secondary insurer is responsible for the remaining 20% coinsurance.
Administration Services
Medicare reimbursement for ALOXI® drug administration services provided in the physician office setting is based on the national fee schedule that is adjusted for geographic variations and updated annually. Medicare reimbursement is based on the lesser of the adjusted fee schedule amount or actual charges, as follows: physicians are reimbursed for 80% of the allowable amount and the patient or patient's secondary insurer is responsible for the remaining 20% coinsurance.
1. See the Medicare Benefits Policy Manual, Chapter 15, section 50 for further information.
