Currentpriority healthPolicy N/A

Medicare Part A vs. Part D Determination Form / Coverage Criteria

Form and criteria to determine whether a requested drug for a hospice-enrolled or non-hospice patient is payable under Medicare Part A (hospice) or Medicare Part D (prescription drug benefit); intended for providers submitting coverage determinations to Priority Health.

Policy Summary

Payerpriority health

PolicyMedicare Part A vs. Part D Determination Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the determination form including hospice enrollment status and clinical rationale when requesting an exception to prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2primary benefit options

1Part A required criterion

2Part D required criteria

2accepted compendia

Coverage Determination Criteria

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Part D (Prescription Drug) Coverage

Covered under Medicare Part D when ALL of the following are met:

Part D coverage criteria: 1) Drug does NOT meet criteria for Medicare Part A coverage; and 2) Drug is used for a medically accepted indication (FDA-approved or supported by specified compendia).

Medically accepted indication defined as FDA approval or support in American Hospital Formulary Service or DRUGDEX.

Provider Responsibilities & Submission Requirements

Prior Authorization

Precertification and documentation required

Prior authorization requires documentation of the member's hospice enrollment and whether the requested drug is being used to treat the hospice diagnosis or a related condition. Providers must complete the Precertification Documentation section answering: A) Is the patient currently enrolled in hospice?; B) Hospice diagnosis; and C) Whether the requested drug is for the hospice diagnosis or related condition (if no, list diagnosis for requested drug).

Confirm hospice enrollment status (Yes/No) and supply hospice diagnosis
Indicate whether the drug is used for the hospice diagnosis or a related condition; if not, list the diagnosis for which the drug is being requested

Denial Risk

Benefit responsibility and exclusion risk

If the drug meets the definition of being used for the patient's terminal illness or a condition related to the terminal illness, coverage responsibility falls under Medicare Part A (hospice). If it does not meet Part A criteria, the drug may be covered under Part D only if it is used for a medically accepted indication and does not otherwise meet Part A coverage criteria. Providers should determine benefit responsibility prior to submission to avoid denial or misbilling.

Drugs for the hospice diagnosis or related conditions = Part A (hospice) coverage
Drugs not meeting Part A criteria must meet Part D rules (medically accepted indication) to be covered under Part D

Documentation Required

Required form documentation

Providers must complete the Priority Health determination/request form fully. Required fields include member identifiers (Last Name, First Name, ID #, DOB), provider identifiers (Requesting Provider, NPI, phone/fax, address, contact name, signature, date), and drug information (new vs continuation request, start date or date of next dose, date of last dose if applicable, drug product, dosing frequency).

Member identifiers: Last Name, First Name, ID #, DOB, PCP, gender assigned at birth
Provider identifiers: Requesting Provider, NPI, provider phone/fax, provider address, contact name, signature, date
Drug information: New or continuation request, start date/next dose date, date of last dose (if applicable), drug product, dosing frequency

Step Therapy

Exception pathway (no explicit step therapy)

An exception pathway is available on the form for requests to waive prior authorization requirements. The provider must indicate if an exception is requested and supply clinical rationale explaining why requirements should be waived. The form asks whether the requested drug is likely the most effective option for the patient and whether changing the current regimen would likely result in adverse effects.

Indicate if an exception to prior authorization requirements is requested (Yes/No) and provide the medical rationale if Yes
State whether the requested drug is likely the most effective option and explain
If the patient is currently using the requested drug, document whether changing therapy would likely cause adverse effects and explain

Initial Requests

Initial requests

Initial request documentation: For new requests provide start date (or date of next dose), drug product, and dosing frequency.

Form includes a checkbox to indicate this is a New request.

Continuation Requests

Continuation requests

Continuation documentation: For continuation requests provide date of last dose and start date or next dose date as applicable.

Form includes a checkbox to indicate this is a Continuation request.

Key Definitions

inv-09: Medically accepted indication — definition and accepted compendia

DefinitionMedically accepted indication: a use of the drug that is either FDA‑approved for the diagnosis/condition or supported by specified compendia.

Accepted compendia (supporting Part D coverage)American Hospital Formulary Service - Drug Information; DRUGDEX Information System.

FDA approval roleIf the FDA has approved the drug for the diagnosis or condition for which it is prescribed, that use qualifies as a medically accepted indication.

Part D applicability (most actionable)This drug is covered under Medicare Part D only when used for a medically accepted indication (FDA‑approved use or supported by the listed compendia).

Step Therapy / Exception Process

Step	Requirement / Note	Provider action
1	No formal step-therapy sequence is specified in this policy; an exception pathway is provided instead.	If requesting an exception to prior authorization, indicate 'Yes' on the exception question and provide a written medical rationale explaining why prior authorization requirements should be waived. Provide clinical reasons why the requested drug is likely the most effective option and whether changing therapy would cause adverse effects.