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ALOXI® Reimbursement Forms

Please note: When billing ALOXI using J2469, the billing unit is 25 mcg.
ALOXI should be billed at 10 units for a 0.25 mg dose.

To access a reimbursement form, simply click on the form you need on the left side of this page. You will be able to view a sample copy of the form as well as download the actual form

Aloxi.com also provides samples of a Letter of Medical Necessity and a Medicare Appeal Letter. Click on the appropriate links on the left to view the samples and download letter templates that you can customize.

You also can access the ALOXI FDA-Approval Letter by clicking on the appropriate link on the left.

*ALOXI is used in adults to help prevent the nausea and vomiting that can happen on the day of treatment with certain chemotherapies or occur days later following certain chemotherapies moderately likely to cause nausea and vomiting.

Tell your healthcare professional if you are taking other medications or if you have or develop severe heartbeat changes. The most common side effects of ALOXI are headache and constipation. ALOXI is available by prescription only. For more information, please see the Patient Product Information for ALOXI.

This site does not contain everything that is known about ALOXI. If you would like to know more, talk to your healthcare professional.

This Web site is intended for U.S. residents only.

Distributed and marketed by MGI PHARMA, INC., Bloomington MN 55437
under license of Helsinn Healthcare SA, Switzerland.
© 2007 MGI PHARMA, INC., Bloomington, MN 55437 U.S.A. AL277 9/07

Please see Important Product Information.