CMS, Hospice Information for Medicare Part D Plans (OMB 0938-1269), § Hospice Information for Medicare Part D Plans (form)

OMB Control Number 0938-1269

Expires 7/31/2028

SECTION I -HOSPICE INFORMATION TO OVERRIDE AN “HOSPICE A3 REJECT” OR TO UPDATE HOSPICE STATUS

A. P urpose of the form (please check all appropriate boxes ) :

Admission Proactive Rx Communication A3 Reject Override Termination

To: Medicare Part D Plan From: Hospice Provider

Plan Name Hospice Name

PBM Name Address

Phone # ( ) - Phone # ( ) -

Fax # ( ) - Fax # ( ) -

Secure E-Mail NPI

Contact Name Contact Name

Plan Sponsor Website Link:

B. Patient Information Prescriber Information

Patient Name Prescriber Name

Patient DOB Prescriber NPI

Patient ID # (MBI) Practice Name

Hospice Admit Date Practice Address

Hospice Discharge Date Contact Name

Principal Diagnosis Code Practice Phone Number ( ) -

Other Diagnosis Code (s) Practice Fax # ( ) -

Unrelated Diagnosis

Code (s)

Hospice Affiliated

YES NO

For change in hospice status update documentation is required. Please check to indicate which document is attached.

Notice of Election Notice of Termination /Revocation

C. Hospice Pharmacy Benefit Manager (PBM) Information

PBM Name BIN Cardholder ID

PBM Phone # ( ) - PCN Group ID

D. Prior Authorization Process: Enter a separate line for each Analgesic, Antinauseant (antiemetic), Laxative, and Antianxiety drug (anxiolytic)

Medication that is Unrelated to Terminal Prognosis . Drugs outside of these four classes do not require prior authorization.

Medication Name and Strength Dosing Schedule Quantity/

Month

Rationale to Support the Medication is Unrelated to Terminal

Prognosis (Optional)

E. Signature of Hospice Representative or Prescriber (Required).

Representative Date / /

Title _______________________________________________

Prescriber* Date / / _

*If the prescriber of the medication is unaffiliated with the Hospice provider, has the prescriber confirmed with

Yes Nothe Hospice provider that the medication is unrelated to the terminal prognosis?

/

Hospice Name

Patient Name

SECTION II – PLAN OF CARE (Optional)

Hospice NPI

Patient ID# () / /Patient DOB

Additional Medications Under Hospice Plan of Care and Designation of Financial Responsibility

Medication Name and Strength Hospice Patient Medication Name and Strength Hospice Patient

Signature of Hospice Representative

Representative Date / /

Signature of Beneficiary or Beneficiary Authorized R epresentative

Beneficiary/Representative Date /