CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Chemotherapy Aloxi (palonosetron) — Form-driven Authorization

Form and requirements for requesting outpatient Aloxi (palonosetron) chemotherapy coverage under the medical benefit for Highmark BlueShield members; used by requesting physicians and facilities to document clinical justification.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Aloxi (palonosetron) — Form-driven Authorization

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Outpatient Chemotherapy Aloxi Request Form with clinical responses and attachments to 1-833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2step agents referenced

833-619-5745fax

Medical Benefit Onlypathway

post-op up to 24halternate indication

Coverage Criteria

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Authorization criteria (form-driven)

Authorization will be considered when the provider supplies all required information and answers the clinical questions listed on the form.

Submission requirements: Form completed with member identifiers, physician and facility details, date of service, J-code(s), diagnosis code(s), and attachments of pertinent clinical information

Required for any authorization review

Clinical justification paths: Either documented failure of BOTH granisetron (Kytril) and ondansetron (Zofran) for chemotherapy-induced nausea/vomiting OR indication as prevention of post-operative nausea and vomiting for up to 24 hours following surgery

Form explicitly asks about both possibilities; provider must indicate which applies

Additional clinical items queried on form: Chemotherapy regimen specified; presence of contraindications to granisetron or ondansetron documented; all pertinent clinical attachments included

Answers to these items are required and missing information may risk denial

The request form does not enumerate discrete not medically necessary conditions. However, failure to provide required clinical responses or supporting attachments — for example, omission of the chemotherapy regimen, prior trials of Kytril (granisetron) and Zofran (ondansetron), or documentation of contraindications — may result in non-authorization of Aloxi.

Initial Therapy Requirements

Initial therapy requirements

Initial authorization is contingent on documented prior therapy or indication.

Initial coverage paths: Documented failure of BOTH Kytril (granisetron) AND Zofran (ondansetron) OR use for prevention of post-operative nausea/vomiting up to 24 hours after surgery

Provider must answer relevant form question and attach clinical information

Step Therapy / Prior Trial Requirements

Documentation Required

Provider Action / Required Documentation

Incomplete clinical information may result in denial of the request. Ensure the form is fully completed and all supporting documentation is attached before submission.

Verify member eligibility and benefits through the health plan prior to submission.
Fax the completed form and all supporting clinical documentation to Highmark at 1-833-619-5745.

Question	Provider must answer
What is the member's chemotherapy regimen?	Provider must state regimen on form
Has the member tried and failed BOTH Kytril (Granisetron) and Zofran (Ondansetron)?	Provider must indicate YES or NO — the form requires confirmation that BOTH agents were tried and failed
Does the member have contraindications to Kytril (Granisetron) or Zofran (Ondansetron)? If so, please list:	Provider must list any contraindications
Is the member to receive Aloxi for the prevention of post-operative nausea and vomiting for up to 24 hours following surgery?	Provider must indicate YES or NO and attach supporting documentation
Please attach all pertinent clinical information	Attach relevant records, prior medication trials, and rationale for Aloxi

Provider Actions & Submission

Prior Authorization

Submit completed Aloxi request form via fax

Fax the completed Outpatient Chemotherapy Aloxi Request Form with all clinical responses and attachments to Highmark at 1-833-619-5745 for medical benefit authorization.

Documentation Required

Include required identifiers, clinical answers, and attachments

Provide a fully completed request form that includes member identifiers, requesting physician and facility details, date of service, J-/diagnosis code(s), answers to the clinical questions on the form, and all pertinent clinical attachments.

Member name, date of birth, UMI
Requesting physician name, NPI, address, contact information
Facility name, NPI, address
Date of service; J-code(s) and diagnosis code(s)
Answers to all clinical questions (chemotherapy regimen, prior trials/failures, contraindications, post-operative use)
Pertinent clinical attachments

Denial Risk

Incomplete clinical information may lead to denial

Failure to answer the clinical questions on the form or to attach pertinent clinical information may result in denial of the Aloxi request.

Definitions

Post-operative prevention — Aloxi (palonosetron)

Form queryIs the member to receive Aloxi for the prevention of post-operative nausea and vomiting for up to 24 hours following surgery?

IndicationPrevention of post-operative nausea and vomiting up to 24 hours after surgery as specifically queried on the Aloxi request form.

Required attachmentProvider must attach all pertinent clinical information documenting the perioperative use, as requested on the form.

Response optionsForm provides checkboxes for YES or NO to indicate whether the request is for post-operative prevention.

Background

Aloxi (palonosetron) is a 5-HT3 receptor antagonist used to prevent chemotherapy- and surgery-related nausea and vomiting. The form collects the member's chemotherapy regimen, whether the member has tried and failed both Kytril (granisetron) and Zofran (ondansetron), any contraindications to those agents, and whether Aloxi is being requested for post-operative prevention (up to 24 hours following surgery). These regimen and prior-treatment details, plus attached clinical information, are required for medical benefit authorization.