PRA Disclosure & Hospice‑Part D Prior Authorization Form Guidance
Guidance and standardized form instructions for coordinating Medicare Part D coverage of drugs for beneficiaries enrolled in hospice, describing uses of the form, who should complete it, and how Part D sponsors, hospices, prescribers, pharmacies, and PBMs should process submissions and A3 rejects. Affects Part D sponsors, hospices, prescribers, pharmacies, and beneficiaries.
No material clinical or coverage changes in this revision.
Coverage Determination & Form Processing
Coverage determination and processing rules
How Part D sponsors/PBMs should treat submissions of the standardized hospice–Part D form and change‑in‑hospice status notifications.
Form completion and signature criteria
Criteria for documenting medications unrelated to terminal prognosis and required signatures:
Point-of-Sale Codes & Patient Identifiers
| A3 | Point-of-sale reject indicating drug may be covered under hospice (Part A) leading to prior authorization requirement |
| MBI | Medicare Beneficiary Identifier used as Patient ID # |
What Providers, Pharmacies, and Plans Must Do
Prior authorization override and A3 reject handling
To prospectively satisfy prior authorization (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 (analgesics, antiemetics/antinauseants, laxatives, anxiolytics), the sponsor/PBM will accept the hospice-Part D 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 applies regardless of how the form is transmitted to the sponsor/PBM (for example, submission through the coverage-determination fax line does not convert the communication into a coverage determination when it is received prior to a claim and is provided by a hospice provider).
- Prospective hospice-Part D form satisfies PA for unrelated drugs in the four specified classes.
- Prospective communications are not coverage determination requests and are accepted regardless of transmission method.
A3 Reject Override Process — Assist the beneficiary in accessing unrelated drugs
When a Part D claim rejects with an A3 reject code, pharmacies should first use the supplemental messaging in the reject to obtain Part D plan contact information and may contact the beneficiary's hospice provider. If the hospice provider cannot be identified after reasonable efforts, the pharmacy may contact the prescriber to confirm the hospice election and whether the prescription is part of the hospice plan of care. For medications determined to be unrelated to the terminal prognosis, the pharmacy should request completion of Section I of the hospice-Part D form by the hospice provider or prescriber and transmit the completed form to the Part D sponsor/PBM to enable an A3 reject override.
- Pharmacy may contact hospice provider using contact info in A3 supplemental message.
- If hospice provider unknown, pharmacy may contact prescriber to verify hospice election and plan-of-care status.
- Request hospice provider or prescriber complete Section I for A3 override and transmit to Part D sponsor/PBM.
Prior Authorization Scope
Scope of prior authorization: Prior authorization fields are required only for drugs in the four categories that may be unrelated to the terminal prognosis: analgesics, antiemetics/antinauseants, laxatives, and anxiolytics. Enter a separate line for each medication in Section D (Prior Authorization Process) with medication name and strength, dosing schedule, quantity/ month, and rationale supporting that the medication is unrelated to the terminal prognosis. Drugs outside of these four classes do not require authorization.
- PA required only for analgesic, antiemetic/antinauseant, laxative, and anxiolytic drugs unrelated to terminal prognosis.
- Section D: one separate line per medication with name/strength, dosing schedule, quantity, and rationale (month/prognosis optional).
- Drugs outside these four classes do not require authorization.
Key Terms & Form Sections
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