Medicare Part D Changes March 1, 2014
In an attempt to provide a concise analysis of the new guideline, the following should be considered:
- Hospices may continue to use medication formularies (such as Enclara’s) to identify those drugs that they will cover for symptom management. If a patient requests a specific non-formulary drug when a formulary drug would work as well, the patient is financially liable for its cost should the hospice not choose to cover it. Part D will not cover the cost of the medication.
- If there is no effective drug on the formulary, CMS expects that the hospice will provide an alternative drug to meet the patient’s needs at the hospice’s expense.
- In the event that a patient or their family requests a drug that the hospice believes is not reasonable or necessary, the patient assumes financial liability. The drug is NOT billable under Medicare Part D and the patient would be presented with an Advance Beneficiary Notice (ABN) notifying the patient of their financial obligation. Examples of these medications may be drugs that are not considered palliative and may have been recommended for discontinuation.
- The exception to item “3” above is for those medications that are completely not related to the patient’s terminal prognosis for which the hospice has clearly documented the rationale why the medication is not related. CMS expects these to be rare occurrences.
ENCLARA is in the process of developing a list of talking points for common medications that are either ineffective or detrimental in the terminally ill. We suggest that your nurses work with ENCLARA pharmacists on formulary alternatives for existing approved non-MAP medications.
Develop a process with your IDT – to discuss relatedness of medications and ensure that your clinical record contains detailed physician documentation as to the determination of all non-related medications. ENCLARA is in the process of developing documentation templates that you can use to satisfy this requirement.