CMS Pub. 100-18, ch. 6, § 10.11

CMS has identified a list of acute care drugs that are most commonly utilized in the home

infusion setting. The use of these drugs or drug classes often results in an earlier hospital

discharge and reduced healthcare costs. Rapid access to these agents is imperative for these

health care transitions. It is CMS’ expectation that Part D sponsors will not implement policies

that could potentially delay or restrict beneficiary access to these important agents. In general,

should prior authorization or other utilization management edits apply to any of these agents,

CMS would expect that Part D sponsors handle these in an expedited manner in order to

facilitate hospital discharge in appropriate time frames. In addition, it is CMS’ expectation that

Part D sponsors ensure appropriate beneficiary access to these drugs or drug classes via

formulary inclusion. See Appendix A for a list of commonly utilized home infusion drugs.

1 If, based on an FDA announcement, a Part D sponsor recognizes and removes a non-Part D drug from its

formulary; CMS expects that Part D sponsors will provide 60 days of advance notice of the formulary removal.