July 18, 2014
CMS issued new guidance related to the Medicare Part D payments for Medicare beneficiaries which supersedes their prior guidance surrounding required pre-authorization for all medications unrelated to the patient’s terminal prognosis.
CMS has limited their prior authorization guidance to only four (4) drug classifications:
In addition to these classifications, CMS states that all medications for the relief of cough and cold, prescription vitamins and OTC medications should also not be processed under the patient’s Medicare Part D benefit. CMS has removed the requirement that Part D sponsors PA any other medications that do not fall into these classifications.
Drugs that fall within the four drug classifications listed above are still eligible for pre-authorization and CMS strongly encourages hospices to submit their prior authorizations on the universal PA form to the Part D sponsor (prior to the initial fill) for those drugs within those classifications that are not related to the patient’s terminal prognosis. CMS continues to advise hospices that there is the expectation that hospice will “continue to provide all of the medications that are reasonable and necessary for the palliation and management of a beneficiary’s terminal illness and related conditions”.
CMS also encourages hospices to allow for a “compassionate first fill” for those drugs that are considered unrelated by the hospice and then negotiate recovery of that fill with the pharmacy adjudicating the claim. Enclara will be issuing internal guidance on that process in the upcoming week.
There is additional non-medication guidance provided related to delays in communication related to a hospice patient’s NOE and change in election that should be noted by our hospice partners, and we have attached the guidance to this clinical alert for your reference. We will continue to review utilization trends in light of this regulatory change and we will be advising further.