CurrentHighmark Blueshield NenyPolicy N/A

Medicare Part D Hospice Prior Authorization for Non‑Hospice Medications

Forms and instructions for hospice providers to request Medicare Part D coverage of prescription drugs believed not to be covered under the Part A hospice benefit; affects hospice providers, prescribers, and PBMs managing Medicare Part D for Highmark members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedicare Part D Hospice Prior Authorization for Non‑Hospice Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a separate prior authorization form for each medication believed unrelated to the terminal illness, including medication details, rationale, hospice and prescriber information, and required signatures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

separate formsubmission requirement

Toll-free faxprimary submission channel

requiredsignature

Medicare Part Dbenefit program

Coverage Criteria for Medicare Part D Hospice Requests

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission content and criteria

Required information and criteria to support a request for Medicare Part D coverage of a medication while a member is in hospice:

ALL of the following

Submit a separate prior authorization form for each medication requested for Part D coverage while the member is in hospice (one form per medication).
Prescriber information: patient name, prescriber name, patient DOB, prescriber NPI, patient ID (HICN), practice name, admit date, practice address, discharge date, contact name, practice phone number, primary and secondary diagnosis, hospice affiliation, and practice fax number.
Medication details: medication name and strength, dosing schedule, quantity per month, and rationale supporting that the medication is unrelated to the terminal illness (rationale field optional).
Signature requirement: signature of the hospice representative or prescriber with dates. If the prescriber is unaffiliated with the hospice provider, indicate whether the prescriber has confirmed with the hospice provider that the medication is unrelated to the terminal illness and/or related conditions (YES/NO).
Submission channel: fax to the listed toll-free number or mail to the Medical Management & Policy address as provided on the form.

One of the following must be provided

Indication that the medication is unrelated to the terminal illness or related conditions (to support Part D coverage).
When applicable, an 'Admission or Discharge Update' entry with relevant dates and status.

Provider Actions and Submission Process

Prior Authorization

Medicare Part D hospice prior authorization — submit separate form per medication

Submit a separate Medicare Part D Hospice Prior Authorization form for each medication believed to be unrelated to the terminal illness; include medication name/strength, dosing schedule, quantity per month, rationale that the medication is unrelated to the terminal illness, hospice and prescriber information, and the required signature(s). Fax the completed form to the listed toll‑free number or mail to Medical Management & Policy as instructed on the form.

One form must be submitted per medication.
Include: medication name and strength, dosing schedule, quantity per month, and rationale that the medication is unrelated to the terminal illness.
Ensure hospice representative or prescriber signature is included; if prescriber is unaffiliated, confirm with hospice whether medication is unrelated to the terminal illness.

Definitions

inv-04: Medications unrelated to terminal illness

DefinitionMedications unrelated to terminal illness and/or related conditions are drugs for which prior authorization is required to request Medicare Part D coverage while the member is in hospice.

Required submission elementsMedication name and strength; dosing schedule; quantity per month; rationale supporting that the medication is unrelated to the terminal illness.

When to useUse this prior authorization process when a hospice patient needs a drug believed not covered under the Part A hospice benefit and Part D coverage is being requested.

Who must signSignature of hospice representative or prescriber is required on the submission.

Optional informationProviding a rationale that the medication is unrelated to the terminal illness is optional but requested to support the coverage determination.