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Documents and Resources

Downloadable forms and documents to assist you with reimbursement processes for ALOXI®.


DOWNLOADABLE FORMS

ALOXI® Annotated CMS-1500 Form

The Form CMS-1500 is the standard paper claim form to bill the Medicare Administrative Contractor when a paper claim is allowed. This form has been annotated to include specific billing and coding information as it relates to ALOXI®.


ALOXI® Annotated CMS-1450 Form

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare Administrative Contractor. This form has been annotated to include specific billing and coding information as it relates to ALOXI®.


ALOXI® Patient Assistance Enrollment Form

This form is used to determine eligibility for the Aloxi Patient Assistance Program.


ALOXI® Insurance Verification Form

This form is used to verify coverage for ALOXI®.


CHECKLISTS

Eisai Checklist for Claims Submission

To facilitate timely and appropriate reimbursement, physicians and their staff should ensure that coding and documentation is complete and accurate.


PATIENT RESOURCES

These foundations offer financial and other assistance (education, counseling, support groups, etc.) to patients.

CancerCare

www.cancercare.org >


Patient Advocate Foundation (PAF)

www.patientadvocate.org >

Assistance Fund (TAF)

www.theassistancefund.org >

Patient Access Network (PAN) Foundation

www.panfoundation.org >

HealthWell Foundations

www.healthwellfoundation.org >

Good Days at Chronic Disease Fund

www.gooddaysfromcdf.org >

Need Coding Information for ALOXI®?

Find coverage information for ALOXI® as determined by payor and setting of care.

Need Tools and Resources to Help Your Patients

ALOXI® provides tools and resources to track Chemo--Induced Nausea and Vomiting symptoms.

Eisai cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payors following the receipt of claims. For additional information, customers should consult with their payors for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record

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Indication in Pediatrics

ALOXI® injection 20mcg/kg (max 1.5mg) is indicated in patients ≥ 1 month up to 17 years of age, for the prevention of acute nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including highly emetogenic chemotherapy.

Indication in Adults

ALOXI® injection 0.25 mg is indicated in adults for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy, and the prevention of acute nausea and vomiting associated with initial and repeat courses of highly emetogenic chemotherapy.

Important Safety Information

Contraindications

  • ALOXI® is contraindicated in patients known to have hypersensitivity to the drug or any of its components
  • Warnings and Precautions

  • Hypersensitivity reactions, including anaphylaxis, have been reported with or without known hypersensitivity to other 5-HT3 receptor antagonists
  • Serotonin syndrome has been reported with 5-HT3 receptor antagonists alone, but particularly with the use of serotonergic drugs. Serotonin syndrome can be life threatening. Symptoms may include the following combination of signs and symptoms: mental status changes, autonomic instability, neuromuscular symptoms, seizures, and gastrointestinal symptoms. Patients should be monitored for the emergence of serotonin syndrome, and if symptoms occur, discontinue ALOXI® and initiate supportive treatment. Patients should be informed of the increased risk of serotonin syndrome, especially if ALOXI® is used concomitantly with other serotonergic drugs

     

    For more information about ALOXI®, please see full Prescribing Information.
    You are encouraged to report negative side effects of prescription drugs to the FDA.
    Visit http://www.FDA.gov/medwatch or call 1-800-FDA-1088.

  • This information is intended for use by our healthcare professionals in the United States only. Eisai Inc. recognizes the Internet is a global communications medium; however, laws, regulatory requirements and medical practices for pharmaceutical products vary from country to country. The Prescribing Information included here is not appropriate for use outside the United States. This site contains information about products that may have different product labeling in different countries. This site is published by Eisai Inc. 

    ALOXI® is a registered trademark of Helsinn Healthcare SA, Switzerland, used under license.
    Distributed and marketed by Eisai Inc and Helsinn Therapeutics (U.S.), Inc.
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