Effective July 18, 2014, the Centers for Medicare & Medicaid Services (CMS) further adjusted prescription coverage guidelines for Medicare members with Part D coverage who are under hospice care. Medicare Part D payers now must require a prior authorization for four classes of medications when prescribed to Medicare members receiving hospice care: analgesics, anti-nauseants (anti-emetics), laxatives and anti-anxiety drugs. (Previously, CMS required prior authorization for all medications prescribed to Medicare members receiving hospice care.) These medications will be covered under Medicare Part D only if they are prescribed for diagnoses unrelated to the member’s terminal illness.
CMS requires Medicare beneficiaries with Part D coverage who are under hospice care to get prior authorization for prescriptions that fall under the drug classes mentioned above. Prescribing doctors may work with Humana to obtain a prior authorization for these prescriptions by calling the Humana Clinical Pharmacy Review Team at 1-800-555-2546, Monday through Friday, 8 a.m. to 6 p.m. EST.
Following are some frequently asked questions and answers for health care providers:
- Q: What should be done if my patient with Medicare Part D coverage, who is also enrolled in hospice, needs medication but his/her prescription coverage through Part D is rejected due to hospice enrollment? A: If the prescribed drug falls under one of the following categories: analgesics, anti-nauseants (anti-emetics), laxatives and anti-anxiety drugs (anxiolytics), the prescribing provider may contact Humana Clinical Pharmacy Review (HCPR) to begin the prior authorization request process by calling 1-800-555-2546 (Puerto Rico providers may call 1-866-488-5991) or via email to HCPR_Hospice@humana.com from 8 a.m. to 6 p.m. EST, Monday through Friday. All other drugs will continue to be subject to standard Part D formulary management practices, including quantity limitations, step therapy, etc.
- Q: What should be done if my patient has recently disenrolled from hospice and needs medication, but his/her prescription coverage through Part D is rejected due to hospice enrollment? A: The patient should contact HCPR by calling 1-800-555-2546 (Puerto Rico providers may call 1-866-488-5991) or via email to HCPR_Hospice@humana.com to request an override. If the patient has a hearing or speech impairment, he or she may call HCPR via TTY: 711.You can also advise the patient to remind his/her hospice provider to update his/her hospice status to prevent further hospice claim denials.