General Description and Overview
The Social Security Act requires hospice programs to provide individuals under hospice care with drugs and biologicals related to the palliation and management of the terminal illness as defined in the hospice plan of care. Hospice drugs are paid under Medicare Part A. Drugs unrelated to the treatment of the terminal illness must be billed to Medicare Part D.
For prescriptions covered under Part A, the pharmacy negotiates a fair and reasonable fee since the hospice provider is paid a capitated rate for services provided. Pharmacists can improve the cost-effectiveness of pharmacotherapy for symptom control in hospice care through patient-specific monitoring for drug therapy outcomes, recommending alternative drug products and dosage forms, minimizing duplicative and interacting medications, compounding medications extemporaneously, improving drug storage and transportation, and educating staff, patients, and families about the most efficient ways of handling, destroying, and using medications.
Pharmacists can expect that drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances. Therefore, the sponsor will place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are covered under Part D. Hospice providers and Part D sponsors agreed and identified the need for a standardized form that would facilitate communication between all involved parties. The form is to be used prospectively (i.e., prior to the submission of claim to Part D) to prevent a drug claim from being rejected at point-of-sale when a drug in any of the four classes is prescribed for a condition that is unrelated to a beneficiary’s terminal prognosis and the beneficiary is prepared to procure the drug.
Learn more about the hospice payment system here.
Learn more about hospice prior authorization procedures and rejection codes here.
Learn more about hospice coordination benefits and view a copy of the form here.