Understanding prescription drug coverage for hospice care

This information may be useful if you’re caring for a hospice patient.

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The Centers for Medicare & Medicaid Services (CMS) recently adjusted prescription coverage guidelines for members under hospice care.

Previously, CMS had required that those in hospice care get prior authorization for any drugs that would be covered by their Part D coverage. As of July 18, 2014, only four drug classes now need prior authorization. They are analgesics, antinauseants, laxatives and antianxiety drugs. The prescribing doctor will need to work with the individual’s Medicare Part D prescription drug insurance carrier to request a prior authorization.

If a member is no longer in hospice, the hospice will need to provide the updated termination information to CMS, which will then be provided to their insurance carrier. Sometimes, a member might leave hospice and need to fill a prescription before the termination information can be forwarded. In these cases, CMS allows insurance carriers to accept specific types of documentation as evidence of the termination of Medicare hospice status. This evidence should be accepted from the beneficiary, the hospice provider, or the prescriber. Once the insurance carrier is aware that a member is no longer in hospice care, the need for a prior authorization for the 4 drug categories will be lifted and the prescriptions will be covered according to the member’s Part D plan benefits.