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CMS Reminder Regarding Hospice and ESRD Drugs

In order to ensure that Medicare patients receiving either hospice or end-stage renal disease (ESRD) care have their prescribed medications correctly covered per their benefits, we would like to remind you of the Centers for Medicare & Medicaid Services’ (CMS’) guidelines for coverage of these medications, which have been in place since 1983. 

Per the direction of CMS, insurers began implementing a point-of-sale rejection note beginning January 1, 2014, for certain drugs (see classes below) dispensed for covered members receiving hospice or ESRD care when submitted by participating pharmacies.  The reason for this is that these particular drugs for this specific type of care are not eligible for Medicare Part D reimbursement, as they are covered under the per diem payment for hospice care or the bundled payment for ESRD-related services. 

Please note that beginning March 1, 2014, members under hospice or ESRD-related care will no longer be able to obtain the medications listed below from a pharmacy under their Medicare Part D benefits.  We’ll be making this change in order to comply with CMS guidelines. 

Hospice Drugs

As hospice care providers receive a per diem payment from Medicare Part A that includes a component for related drug costs, participating pharmacies should look to the hospice care provider for payment and not the patient’s insurer.  Analgesics, antinauseants (antiemetics), laxatives, and anti-anxiety drugs used primarily for the relief of pain and symptom control related to the patient’s terminal illness are included. 

End-Stage Renal Disease Drugs

As dialysis facilities receive bundled payments from Medicare Part B that includes a component for related drug costs, participating pharmacies should look to the dialysis facility provider for payment and not the patient’s insurer.  Antiemetics, anti-infectives, antipruritic, anxioytic, excess fluid management, fluid and electrolyte management including volume expanders, and pain management drugs used in the care of ESRD patients are included. 

Appeals of Rejected Claims

If the patient was not an active hospice or ESRD patient at the time of the date of service, the prescribing provider, participating pharmacy, or covered member may appeal a rejected claim by submitting documentation confirming the patient’s status when the drug was dispensed to Prime’s Clinical Review Department via fax at 1-800-693-6703 or by phone at 1-800-693-6651.