Earlier this year the Centers for Medicare & Medicaid Services (CMS) clarified the criteria for determining payment responsibility under the Part A hospice benefit and Part D prescription drug benefit for individuals who are under the Medicare hospice benefit. This was done to help prevent duplicate payments. CMS has issued a new guidance that requires denial of Part D claims on the basis of Prior Authorization (PA) for Medicare members who choose the hospice benefit after May 1, 2014.

What is a “prior authorization” of a prescription drug?

This is usually when the Medicare Part D plan will cover a particular drug, but your doctor must first show the plan that it is medically necessary for you to have that particular drug. The plans also do this to be sure that the drugs are used correctly. In this new scenario the Medicare Part D plan must confirm who is responsible for paying for the drug; the hospice benefit or the prescription drug benefit. This will also reduce the number of inaccurate claims.

What medications does hospice benefit pay?

This benefit will pay for medications that ease the suffering and help in pain management in a terminal condition. The Medicare approved Hospice provider will supply the medications and the copayment to the individual will be no more than $5.00 per prescription.

What does Medicare Part D pay for?

Your Part D plan will pay for those maintenance prescriptions not related to the hospice benefit. Medications for things like high blood pressure, heart disease, diabetes and other chronic conditions. Under this new guidance these medications will require prior authorization,

What can I or my caregiver do so that there is not a delay in getting the medications I need?

First, whenever possible order your refills at least seven days before your current prescription runs out. Call your Medicare Part D plan to ask for the forms and process in requesting a “coverage determination”. Talk with your hospice provider or nurse on what prescription drugs are under your hospice benefit.

Please call for more information about this or other Medicare subjects. We have trained and certified counselors available to help navigate the Medicare health care system. If you have a group that would like more information about the upcoming Medicare Open Enrollment Period (October 15 – December 7, 2014) we are available for community presentations and annual Medicare screenings. And always, we are looking for individuals who would like to help their community by becoming a Hawaii SHIP Volunteer.


Hawaii SHIP (State Health Insurance Assistance Program)
1-888-875-9229 | 808-586-7299
help@hawaiiship.org | www.hawaiiship.org
For 2014 Medicare updates: www.medicare.gov