CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Chemotherapy Aloxi Request Form

A fillable fax form for clinicians to request Aloxi (palonosetron) for outpatient chemotherapy patients under the medical benefit; used by requesting physicians and facilities to provide member and clinical details to Highmark Blue Shield NE NY.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Aloxi Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Outpatient Chemotherapy Aloxi Request Form with member, physician, facility, date of service and diagnosis code(s) to 833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2form pages/chunks

833-619-5745fax number

Medicalbenefit type

Verify eligibilityreminder

Requested Clinical Criteria

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Aloxi Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Outpatient Chemotherapy Aloxi Request Form with member, physician, facility, date of service and diagnosis code(s) to 833-619-5745.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

What is the member's chemotherapy regimen?
Does the member have contraindications to Kytril (Granisetron) or Zofran (Ondansetron)? If so, list.
Is the member to receive Aloxi for the prevention of post-operative nausea and vomiting for up to 24 hours following surgery?
Attach all pertinent clinical information.

Please verify member's eligibility and benefits through the health plan (administrative requirement).

Eligibility/benefit verification is requested on the form.

Diagnosis and Provider Identifiers

Diagnosis codes (requester-entered)ICD-10

Field for Diagnosis Code(s) to be provided by requester

NPI and Facility Identifiers Required

Requesting physician NPIForm includes field labeled 'NPI Number' for the requesting physician

Facility NPIForm includes field labeled 'Facility NPI Number' for the servicing facility

Requesting physician identification fieldsForm collects Requesting Physician's Name, Address, Office Contact, Phone, and Fax

Facility identification fieldsForm collects Facility name and Facility's Address

Submission and Documentation Requirements

Prior Authorization

Submission instructions — fax completed form to 833-619-5745

Complete and fax the Outpatient Chemotherapy Aloxi Request Form with member, physician, facility, date of service and diagnosis code(s) to 833-619-5745 for Medical Benefit claims.

Include Member Name, Date of Birth, UMI and payer type
Provide Requesting Physician name and NPI
Provide Facility name and Facility NPI
Enter Date of Service and Diagnosis Code(s)

Documentation Required

Clinical information required — attach pertinent records and answer form questions

Attach all pertinent clinical information and answer the clinical questions on the form about the member's chemotherapy regimen, contraindications to Kytril (Granisetron) or Zofran (Ondansetron), and whether Aloxi is intended for prevention of postoperative nausea and vomiting up to 24 hours following surgery.

What is the member's chemotherapy regimen?
Does the member have contraindications to Kytril (Granisetron) or Zofran (Ondansetron)? If so, list.
Is Aloxi intended for prevention of postoperative nausea and vomiting for up to 24 hours following surgery?
Confirm pertinent clinical documentation is attached

Form Description

Outpatient Chemotherapy Aloxi Request Form

Form purposeOutpatient Chemotherapy Aloxi (palonosetron) request form for Medical Benefit claims; to be completed and faxed to 833-619-5745

Member identifiersMember Name, Member Date of Birth, Member UMI

Physician and facility fieldsRequesting Physician's Name, NPI Number, Address, Office Contact, Phone, Fax; Facility, Facility NPI Number, Facility's Address

Service and coding fieldsDate of Service and Diagnosis Code(s) fields present for requester entry

Clinical questions requiredQuestions requesting chemotherapy regimen, contraindications to Granisetron or Ondansetron, and whether Aloxi is for prevention of postoperative nausea and vomiting up to 24 hours