US · guidance
CMS, Hospice Information for Medicare Part D Plans (OMB 0938-1269), § Prescriber
Prescriber
To provide information to override an A3 reject:
Prescribers will:
• Identify the beneficiary’s Medicare Part D plan and obtain the appropriate fax number or other
contact information to which the completed form should be directed.
• Complete Section 1 reporting each drug that is unrelated to the terminal prognosis.
• Transmit the completed form to the beneficiary’s Medicare Part D plan.
Prescribers unaffiliated with the hospice provider should also:
Contact the hospice provider to confirm that the medication is unrelated to the terminal prognosis, and
check the box on Page 1 under the prescriber’s signature.
A signature indicates that the prescriber is aware that a medication is unrelated to the hospice
prognosis. Part D sponsor may need to process more than one form for a beneficiary who is has
multiple prescribers.
History
Standardized form and instructions for Part D coverage of drugs for beneficiaries enrolled in hospice (OMB control number 0938-1269), as posted on the CMS Hospice page 2026-09-17.
Provenance
- Source
- cms.gov
- Retrieved
- 2026-09-17
- Edition
- hospice-memos-2026-09-17
- Content hash
f4aec69a03daf0236e260ef4ac9326a2936d9814fc9c7b2ae141ac491b8fa1a3
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