vp-0008
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Aloxi® (palonosetron) (Intravenous)

Policy Number: VP-0008

Last Review Date: 04/03/2019

Date of Origin: 10/17/2008

Dates Reviewed: 06/2009, 12/2009, 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016, 02/2017, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 04/2019

  1. Length of Authorization

Coverage is provided for six months and may be renewed. Coverage cannot be renewed for the indication of PONV.

  1. Dosing Limits
  1. Quantity Limit (max daily dose) [Pharmacy Benefit]:
  • Aloxi 0.25 mg/5 mL solution for injection: 1 vial per 7 day supply
  • Aloxi 0.075 mg/1.5 mL solution for injection: 1 vial
  1. Max Units (per dose and over time) [Medical Benefit]:

Chemo-induced N/V:

  • 10 billable units per 7 days

Post-Op N/V:

  • 3 billable units as one time only
  1. Initial Approval Criteria

Coverage is provided in the following conditions:

Prevention of Chemotherapy induced Nausea and vomiting (CINV) in Adults †

  • Patient is receiving highly emetogenic chemotherapy (HEC)*; OR
  • Patient is receiving moderately emetogenic chemotherapy (MEC); AND
  • Palonosetron is NOT covered for:
    • Breakthrough emesis; OR
    • Repeat dosing in multi-day emetogenic chemotherapy regimens

Prevention of Chemotherapy induced Nausea and vomiting (CINV) in Pediatric Patients †

  • Patient is at least 1 month old and less than 17 years old; AND
  • Patient is receiving emetogenic chemotherapy; AND
  •  Palonosetron is NOT covered for:
  • Breakthrough emesis; OR
    •  
  • Repeat dosing in multi-day emetogenic chemotherapy regimens

Prevention of post-operative nausea and vomiting (PONV) in Adults †

*Highly emetogenic chemotherapy (HEC):

Highly Emetogenic Chemotherapy (HEC)

Carboplatin

Cyclophosphamide

Epirubicin

Streptozocin

Carmustine

Dacarbazine

Ifosfamide

Cisplatin

Doxorubicin

Mechlorethamine

The following chemotherapy can be considered HEC in certain patients:

Dactinomycin

Daunorubicin

Irinotecan

Methotrexate ≥ 250 mg/m2

Oxaliplatin

Trabectedin

The following regimens can be considered HEC:

FOLFOX

** Failure is defined as:

  • Two or more documented episodes of vomiting attributed to the current chemotherapy regimen

FDA-approved indication(s)

  1. Renewal Criteria

Coverage can be renewed based upon the following criteria:

    • Patient continues to meet the criteria identified in section III; AND
    • Disease response; AND
    • Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: serotonin syndrome, severe QT prolongation, hypersensitivity, etc.
  1. Dosage/Administration

Indication

Dose

Prevention of chemotherapy-induced nausea and vomiting in adults

0.25 mg, no more frequently than weekly, prior to highly emetogenic chemotherapy

Prevention of chemotherapy-induced nausea and vomiting in pediatrics

20 mcg/kg (max of 1.5 mg), no more frequently than weekly, prior to emetogenic chemotherapy

Post-operative nausea and vomiting

0.075 mg given immediately before anesthesia

  1. Billing Code/Availability Information

Jcode:

J2469 – Injection, palonosetron HCl, 25 mcg: 1 billable unit = 25 mcg (0.025 mg)

NDC:

  • Aloxi 0.25 mg/5 mL solution for injection; single-dose vial: 62856-0797-xx
  • Aloxi 0.075 mg/1.5 mL solution for injection; single-dose vial: 62856-0798-xx (not commercially available)

Generics available from multiple manufacturers

  1. References
  1. Aloxi [package insert]. Switzerland; Helsinn Healthcare SA; September 2018. Accessed February 2019.
  2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) palonosetron. National Comprehensive Cancer Network, 2019. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc.” To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed February 2019.
  3. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Antiemesis. Version 2018. National Comprehensive Cancer Network, 2019. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc.” To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed February 2019.

Appendix 1 – Covered Diagnosis Codes

ICD-10

ICD-10 Description

R11.0

Nausea

R11.10

Vomiting, unspecified

R11.11

Vomiting without nausea

R11.12

Projectile vomiting

R11.2

Nausea with vomiting, unspecified

T41.0X5A

Adverse effect of inhaled anesthetics, initial encounter

T41.1X5A

Adverse effect of intravenous anesthetics, initial encounter

T41.205A

Adverse effect of unspecified general anesthetics, initial encounter

T41.295A

Adverse effect of other general anesthetics, initial encounter

T41.45XA

Adverse effect of unspecified anesthetic, initial encounter

T45.1X5A

Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter

T45.1X5S

Adverse effect of antineoplastic and immunosuppressive drugs, sequela

T45.95XA

Adverse effect of unspecified primarily systemic and hematological agent , initial encounter

T50.905A

Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter

T88.59XA

Other complications of anesthesia, initial encounter

Z51.11

Encounter for antineoplastic chemotherapy

Z51.12

Encounter for antineoplastic immunotherapy

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD): N/A

Medicare Part B Administrative Contractor (MAC) Jurisdictions

Jurisdiction

Applicable State/US Territory

Contractor

E (1)

CA,HI, NV, AS, GU, CNMI

Noridian Healthcare Solutions, LLC

F (2 & 3)

AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ

Noridian Healthcare Solutions, LLC

5

KS, NE, IA, MO

Wisconsin Physicians Service Insurance Corp (WPS)

6

MN, WI, IL

National Government Services, Inc. (NGS)

H (4 & 7)

LA, AR, MS, TX, OK, CO, NM

Novitas Solutions, Inc.

8

MI, IN

Wisconsin Physicians Service Insurance Corp (WPS)

N (9)

FL, PR, VI

First Coast Service Options, Inc.

J (10)

TN, GA, AL

Palmetto GBA, LLC

M (11)

NC, SC, WV, VA (excluding below)

Palmetto GBA, LLC

L (12)

DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA)

Novitas Solutions, Inc.

K (13 & 14)

NY, CT, MA, RI, VT, ME, NH

National Government Services, Inc. (NGS)

15

KY, OH

CGS Administrators, LLC