Medicare Part D Hospice Prior Authorization for Non‑Hospice Medications
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Medicare Part D Hospice Requests
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.
PBM / Identifiers and Coding
| PBM Name | PBM Name |
| BIN | BIN |
| Cardholder ID | Cardholder ID |
| PBM Phone Number | PBM Phone Number |
| PCN | PCN |
| Group ID | Group ID |
Provider Actions and Submission Process
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
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