CMS Eases Scope of PA for Part D Beneficiaries on Hospice: Limits PA to 4 Drug Categories Identified by OIG as a Concern
On July 18, 2014 the Centers for Medicare & Medicaid Services (CMS) released a memorandum, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice, which updates the guidance previously released in March. Under the new guidance, in lieu of placing a beneficiary-level prior authorization (PA) on all drugs for beneficiaries who have elected hospice, CMS strongly encourages Part D sponsors to place beneficiary-level PA requirements on only four categories of prescription drugs: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics).
Drugs prescribed for hospice patients under these four categories and paid for under Part D were the subject of a 2012 Office of the Inspector General (OIG) report in which concerns were raised that Medicare may be paying twice for drugs for hospice patients -- once under the bundled hospice per diem that includes drugs that are prescribed for the terminal diagnosis and related conditions and again under Part D.
In the memo, CMS conveys that it expects that medications in these four drug classes will rarely be unrelated to the patient’s principal terminal diagnosis and related conditions so hospice will be paying for these medications most of the time. While CMS indicates that the change is effective immediately and strongly encourages plans to implement the guidance as soon as possible, plans MUST implement the guidance by until Oct. 1, 2014.
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