Medicare Part D Changes

In July 2014, CMS issued new guidance related to the Medicare Part D payments for Medicare beneficiaries that supersede its prior guidance surrounding required pre-authorization for all medications unrelated to the patient’s terminal prognosis.

CMS has limited its prior authorization guidance to only 4 drug classifications:

  • Analgesics
  • Antinauseants
  • Laxatives
  • Antianxiety medications

In addition to these classifications, CMS states that all medications for the relief of a 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 don’t 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 aren’t 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 file with the pharmacy adjudicating the claim.

There is additional non-medication guidance provided related to delays in communication-related to a hospice patient’s NOE and change in the election that should be noted by hospices, and we have provided links to the guidance to this clinical alert below. We will continue to review utilization trends in light of this regulatory change and will be advising further.

To note: Enclara Pharmacia supported its customer base through these regulatory changes and developed a ‘toolbox’ of education and guidelines to assist its customers to remain compliant while anticipating the practice and cost implications. These tools remain available upon request.