Downloadable forms and documents to assist you with reimbursement processes for ALOXI®.
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®.
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®.
This form is used to determine eligibility for the Aloxi Patient Assistance Program.
To facilitate timely and appropriate reimbursement, physicians and their staff should ensure that coding and documentation is complete and accurate.
These foundations offer financial and other assistance (education, counseling, support groups, etc.) to patients.
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
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.
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.
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.