CMS, Hospice Information for Medicare Part D Plans (OMB 0938-1269), § Medicare Part D Plan Sponsor/PBM

To prospectively satisfy PA requirements for a member enrolled in hospice:

When a Part D sponsor/PBM receives prospective notification of drug information from the hospice

provider indicating that a beneficiary who has elected hospice is using Part D drugs in the four

categories that are unrelated to the terminal illness, the sponsor/PBM will accept the form and use it

to satisfy the PA requirement. These prospective communications are not requests for coverage

determinations and need not comply with coverage determination timeframes and notice

requirements. This is the case regardless of how the form is transmitted to the plan sponsor/PBM.

For example, even if the notification is sent through the coverage determination fax line, it would not

be considered a coverage determination because it was communicated prior to the sponsor/PBM’s

receipt of a claim and a hospice provider cannot request a coverage determination.

To override A3 reject:

When the necessary information has been provided, the sponsor/PBM will override the A3 reject for the

medications listed as being unrelated to the terminal prognosis. In order for the request to be considered

complete all fields in Section I must be completed EXCEPT for the following:

Part A Plan sponsor Website Link

Hospice Pharmacy Benefit Manager (PBM) Information if not applicable

Upon receipt of the completed form, the Part D sponsor will override the A3 reject for the drugs listed. In

addition the Part D sponsors will concurrently obtain and review the information necessary to promptly

determine whether any applicable drug-specific UM requirement has been satisfied (or, alternatively,

whether an exception to that UM requirement has been requested).

To process a change in hospice status:

When the necessary information has been provided, the plan sponsor/PBM will use the information

submitted on and with the form as Best Available Evidence (BAE) to update the beneficiary’s hospice

enrollment status. In order for the request to be considered complete the following fields in Section I must

be completed:

Part A

Part B, Patient Name, DOB, Patient MBI# Prescriber, Name, Prescriber NPI

An indication whether an NOE or NOTR is attached

The appropriate form must be attached

The plan sponsor/PBM will ensure that the beneficiary’s hospice information is reflected in the sponsor’s

systems until a Transaction Reply Report (TRR) is received from CMS with the updated

election/termination information.

Use of plan of care information:

The plan sponsor/PBM may receive a form with the Section II completed. Although completion of Section

II, which provides the plan of care information, is optional (i.e., it is not required to either override the A3

reject or communicate a change in the beneficiary’s hospice status), it is encouraged. When received by the

sponsor/PBM, the information regarding the additional medications prescribed and the responsible financial

party will assist the sponsor in their utilization review and coordination of care activities.