In its latest guidance about Part D medication, CMS on Friday removed many drugs from the list of medications requiring preauthorization for hospice beneficiaries.
 
Effective now, Part D sponsors only need prior authorization on four categories of drugs: analgesics, antinauseants, laxatives and antianxiety drugs. 
 
As for pending coverage determinations involving previously rejected claims for drugs other than those in the four categories, “the drugs should be considered covered under the Part D benefit without the sponsor obtaining documentation regarding the relatedness of the drug,” CMS says in a memo today to all Part D plan sponsors and Medicare hospice providers.
 
CMS’ guidance is “very helpful” because it removes the need for preauthorization for drugs such as insulin, cardiac medicine and antihypertensives, says Katie Wehri, hospice operations expert for the National Association of Home Care & Hospice (NAHC).
 
That guidance will “reduce the confusion for hospice providers and will allow patients to get their medications when they need them,” J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization (NHPCO), says in a news release.
 
Prior guidance — which took effect May 1 — states that hospices must provide “a coherent clinical explanation” to the patient’s Part D plan about why a drug is medically necessary but unrelated to a patient’s terminal condition and therefore not a cost the hospice needs to cover (HHL 5/12/14). That guidance applied to all drugs, not just the four categories. And without a coherent explanation, the plan need not pay, CMS had said.
 
The hospice industry had dozens of organizations — including NAHC, AARP, the American Medical Association and NHPCO — joining in opposition to CMS’ instructions earlier this year.
 
An NHPCO survey of hospice professionals found the prior policy left many Medicare beneficiaries without needed medications while other dying patients revoked or refused the hospice benefit so they could to maintain access to medications unrelated to their terminal prognosis.
 
CMS’ goal for its policy was to ensure that hospices and Part D programs correctly pay for prescription drugs covered under each respective Medicare benefit, while ensuring timely access to the needed drugs, CMS says in today’s memo.
 
The objective hasn’t changed, but CMS recognizes that operational challenges associated with preauthorizing all drugs for hospice beneficiaries “have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries,” the memo states.
 
Although the latest guidance is effective now, sponsors have until Oct. 1 to implement the changes.
 
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