Currentpriority healthPolicy N/A

Medicare Part A vs. Part D Determination Form

Form and criteria to determine whether a drug for a hospice/enrolled patient is covered under Medicare Part A (hospice) or Medicare Part D (prescription drug) and to document Part D exception requests. Affects providers requesting coverage/precertification from Priority Health for Medicare beneficiaries in hospice contexts.

Policy Summary

Payerpriority health

PolicyMedicare Part A vs. Part D Determination Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Medicare Part A vs Part D Determination Form including member and provider identifiers, drug details, hospice enrollment and diagnosis, and provide clinical justification for any Part D exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2benefit options on form

1Part A coverage test

2Part D requirements listed

2compendia cited

Coverage criteria for Medicare Part A vs Part D

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.

Part A (Hospice) Coverage

Covered under Medicare Part A when ALL of the following are met

Part A coverage condition: Drug must be used for the patient's terminal illness or a condition related to the terminal illness.

Applies even if prescriber unaffiliated with hospice, drug not on hospice formulary, not medically necessary, or waived through hospice election.

Part D (Prescription Drug) Coverage

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

Part D coverage conditions: 1) Drug does not meet Part A hospice coverage criteria; and 2) Drug is used for a medically accepted indication.

Medically accepted indication = FDA-approved use or supported by AHFS or DRUGDEX compendia.

Drugs paid for under the Medicare Part A per-diem payments to a Medicare hospice program are excluded from coverage under Medicare Part D. This exclusion follows Medicare guidance identifying medications covered under the Part A hospice benefit as not eligible for Part D coverage.

Provider documentation, precertification, and exception requirements

Prior Authorization

Precertification and Part D exception requirements

Providers must indicate whether the patient is enrolled in hospice, the hospice diagnosis, and whether the requested drug is being used for the hospice diagnosis or a related condition. This information is required on precertification requests to determine Medicare Part A vs Part D responsibility.

A. Is the patient currently enrolled in hospice? Yes / No
B. Hospice diagnosis — list diagnosis
C. Is the requested drug being used for the hospice diagnosis or a related condition? Yes / No. If No, list diagnosis for requested drug

Denial Risk

Coverage determination exclusion risk

Drugs paid for under the Medicare Part A per‑diem payments to a Medicare hospice program are excluded from Medicare Part D coverage. Determine benefit responsibility (Part A vs Part D) before approving or billing a requested drug; drugs used for the patient’s terminal illness or related conditions are covered under Part A.

If drug is paid under Medicare Part A hospice per‑diem, it is excluded from Part D coverage
Benefit determination must be completed prior to coverage or billing

Documentation Required

Required form documentation

Providers must complete the Medicare Part A vs Part D Determination Form and include member identifiers, provider information (name, NPI, contact), drug details (product, dosing, new vs continuation, start/last dose dates), and signature/date. For Part D exception requests include clinical justification addressing why prior authorization or step requirements should be waived, why the drug is likely the most effective option, and whether changing therapy would likely cause adverse effects.

Member identifiers: name, ID#, DOB, PCP
Provider: name, phone, fax, address, NPI, contact, signature, date
Drug info: new vs continuation, product, dosing frequency, start date, date of last dose
For exceptions: provide medical justification why requirements should be waived, why drug is most effective, and potential adverse effects if therapy changed

Key definitions

Medically accepted indication

DefinitionA use of the drug that is either FDA‑approved for the diagnosis/condition prescribed or supported by compendia (American Hospital Formulary Service - Drug Information or DRUGDEX).

FDA‑approved useIndication is covered if the FDA has approved the drug for the diagnosis or condition for which it is prescribed.

Compendia supportAlternatively, coverage applies when the use is supported by AHFS Drug Information or the DRUGDEX Information System.

Coverage implication (most actionable)This drug is covered under Medicare Part D only when used for a medically accepted indication (i.e., FDA‑approved or compendia‑supported).

Criteria for continuation therapy and exceptions

Continuation Therapy / Exception

Documentation for continuation requests and exception when patient is already using the drug

Continuation request documentation: If patient is currently using requested drug, indicate continuation request, provide date of last dose, and state whether changing regimen would likely result in adverse effects with supporting explanation.

Supports Part D exception rationale.

Requirement	Provider response / documentation
Statement explaining medical reason for exception (why prior authorization requirement should be waived)
Indicate whether requested drug is likely the most effective option for this patient and provide supporting rationale if Yes
If patient is currently using the requested drug, state whether changing therapy would likely cause adverse effects and provide clinical explanation if Yes