CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice (July 18, 2014), § Standardized prior authorization form

Representatives from the prescription drug and hospice industries participating in the National

Council for Prescription Drug Program’s Work Group 9 Hospice Task Group have collaborated

on the development of a draft two-page form that may be used either by the hospice or prescriber

to provide the information necessary to satisfy the beneficiary-level prior authorization edit, for

the sponsor to make a coverage determination, or by the hospice to prospectively communicate

information to the Part D sponsor. The first page of the form captures the information necessary

for the prior authorization of drugs in the four categories; the second page captures information

on drugs related to the terminal illness and/or related conditions and specifies whether each of

these drugs is the responsibility of the hospice or beneficiary. Although not required for either a

prior authorization or a coverage determination, the second page provides information to support

the Part D sponsor’s coordination of care efforts, such as safety edits for drug-drug interaction.

Given the broad industry support for the form, we are using it to replace the list of data elements

we identified in Attachment 2 of the March 10, 2014 memorandum for inclusion in a Part D

hospice PA form. We have made minor edits to the draft form (a copy of the edited version is

attached) and we strongly recommend sponsors use the first page of the form as edited until a

standard Part D hospice PA form is approved. Because only drugs that are unrelated to the

terminal illness and related conditions would be reported on this page of the form, listing the

drug here in effect constitutes a statement by the hospice provider or the prescriber that the drug

is unrelated. The form provides space for a rationale to support the drug is unrelated; however,

no clinical justification for that determination is necessary.

While hospice providers are not required to complete the second page of the form, should they

choose to complete it, the information will assist sponsors in care coordination activities.

Although we encourage Part D sponsors and hospice providers to use this two-page form,

sponsors should not require its use. As long as the necessary statement that the drug is unrelated

is provided, the sponsors should accept it in any format.

Note: the first page of the form could also be used by the hospice provider to report only a

beneficiary’s hospice election or termination. In these cases, the hospice could use the patient

information section to report the appropriate date and check the box to indicate the form is being

used solely to update a hospice election (admission) or termination (discharge).

Retrospective review and recovery of Part D payment for drugs in the four categories

As noted above, we do not expect Part D sponsors to retrospectively review paid claims for

drugs outside of the four categories specifically for the purpose of determining whether the drugs

were unrelated to the hospice beneficiary’s terminal illness and related conditions. However, all

Part D retrospective review requirements continue to apply to these claims.

If the Part D sponsor has paid claims for drugs in the four categories for hospice beneficiaries

prior to receiving notification of the beneficiary’s hospice election, the sponsor should perform a

subsequent review of claims paid within the hospice election period for drugs in the four

categories and should also conduct outreach to the hospice provider or prescriber to

retrospectively determine payment responsibility for the drugs. In order to determine whether

the drug is for treatment of a condition unrelated to the terminal illness or related conditions,

CMS expects the prescriber or hospice provider to coordinate with the plan sponsor regarding

these claims and provide the necessary written or verbal statement that the drug is either (1)

unrelated to the terminal illness or related conditions or (2) is a beneficiary liability.

In those scenarios in which the drug is determined to be a hospice liability, the sponsors and

hospices should negotiate repayment. In the scenarios in which the beneficiary is liable, such as

when the member has requested a non-formulary drug from the hospice and refused to try a

formulary equivalent, or the drug was determined by the hospice provider to be unreasonable or

unnecessary, but the beneficiary agreed to assume financial responsibility for it, the sponsor

should send a recovery notice to the beneficiary.

Sponsors should implement processes to handle payment resolution directly with hospice

providers and beneficiaries without requiring the pharmacy reverse and rebill the original claim

in the retail setting. However, whenever the network pharmacy involved is also the hospice

pharmacy, as is often the case with long-term care pharmacies, reverse and rebill may be the

most appropriate approach.