CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Hospice—Final 2014 Guidance (Mar. 10, 2014), § Drugs That Are a Beneficiary Liability

There may also be some drugs that were for the treatment of the terminal illness and/or related

conditions prior to the hospice election that will be discontinued upon hospice election, as it has

been determined by the hospice interdisciplinary group, after discussions with the hospice patient

and family, that those medications may no longer be effective in the intended treatment, and/or

may be causing additional negative symptoms in the individual. These medications would not be

covered under the Medicare hospice benefit, as they would not be reasonable and necessary for

the palliation of pain and/or symptom management. If a beneficiary still chooses to have these

medications filled through his or her pharmacy, the costs of these medications would then

become a beneficiary liability for payment and not covered by Part D. These medications would

not be covered by Part D because their further coverage is prohibited under Medicare.

Similarly, if a beneficiary requests a drug for his or her terminal illness or related conditions that

is not on the hospice formulary and the beneficiary refuses to try a formulary equivalent first; or

the drug is determined by the hospice provider to be unreasonable or unnecessary for the

palliation of pain and/or symptom management, the beneficiary may opt to assume financial

responsibility for the drug. However, no payment for the drug will be available under Part D.

When a drug is determined by the hospice provider to be the beneficiary’s responsibility, Part D

has no payment responsibility and payment coordination is not an issue. In those situations

involving retrospective payment recovery, as discussed in the payment recovery section below,

the sponsor should issue a recovery notice to the beneficiary.