CurrentHighmark PennsylvaniaPolicy N/A

Medicare Part D Hospice Prior Authorization Form for Non‑Hospice‑Covered Medications

This document provides the form and instructions for requesting Medicare Part D coverage of prescription medications for members in hospice when the drug is believed not to be covered under the hospice (Part A) benefit. It applies to hospice providers, prescribers, and pharmacy benefit managers working with Highmark Pennsylvania members.

Policy Summary

PayerHighmark Pennsylvania

PolicyMedicare Part D Hospice Prior Authorization Form for Non‑Hospice‑Covered Medications

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate Medicare Part D hospice prior authorization form for each medication believed to be unrelated to the terminal illness.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form to submit per medication

1-866-240-8123toll-free fax for submission

Mailalternative submission

Yessignature required

When Part D Coverage Is Requested for Hospice Patients

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Submission criteria

When requesting Part D coverage for a hospice patient:

Submit a separate form for each medication.

Provide hospice provider, hospice PBM, prescriber, and patient information as requested on the form (e.g., NPI, patient ID/HICN, diagnoses, medication name/strength, dosing, quantity per month).

Include a rationale supporting that the medication is unrelated to the terminal illness (optional field available on the form).

If the prescriber is unaffiliated with the hospice provider, indicate whether the prescriber confirmed with the hospice that the medication is unrelated to the terminal illness (Yes or No).

Ensure the signature of the hospice representative or prescriber is present; indicate if the submission is an admission or discharge update only.

Provider Submission Requirements and Instructions

Prior Authorization

Submit one form per medication

Submit a separate Medicare Part D hospice prior authorization form for each medication when requesting coverage for medications believed to be unrelated to the terminal illness (i.e., not covered under the Part A hospice benefit).

Documentation Required

Fax/mail form and include signature

Fax or mail the completed form to Medical Management & Policy using the toll‑free fax number or mailing address provided. Ensure the signature of the hospice representative or prescriber is included and indicate if the submission is an admission or discharge update; also document whether the prescriber (if unaffiliated) confirmed the medication is unrelated to the terminal illness.

Toll Free Fax #: 1-866-240-8123
Mailing Address: Medical Management & Policy, 120 Fifth Avenue, SPECARE · Pittsburgh, PA 15222
Include hospice representative or prescriber signature and date
Indicate ADMISSION OR DISCHARGE UPDATE ONLY and YES/NO confirmation as applicable

Key Definitions

Unrelated medication — Medication unrelated to terminal illness

Defined termUnrelated medication

MeaningMedication believed to be not covered under the Part A hospice benefit because it is unrelated to the patient’s terminal illness or related conditions.

Submission implicationUse the Medicare Part D Hospice Prior Authorization form to request Part D coverage for each medication identified as unrelated to the terminal illness.

Documentation requiredInclude medication name/strength, dosing, quantity per month, primary/secondary diagnosis, and optional rationale supporting that the medication is unrelated to the terminal illness.

Prescriber confirmationIf prescriber is unaffiliated with the hospice, indicate whether the prescriber confirmed with the hospice that the medication is unrelated to the terminal illness (Yes/No).