Aloxi® (palonosetron)

Prior authorization required for home infusion providers only 

Home Infusion Services Authorization Request

 

 No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

 

Code(s): J2469

Benefit: Medical

Notes: Per 25 mg, antiemetic, PA required for HINF provider ONLY