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New CMS Guidelines Regarding Prescription Drugs for Hospice Patients

The Centers for Medicare & Medicaid Services has recently provided clarification regarding their guidelines, which have been in place since 1983, for the coverage of medications used by hospice patients. 

Per the direction of CMS, BCBSNC Prescription Medicare Part D plans began implementing point-of-sale edit notes on January 1, 2014, for four classes of medications: analgesics, anti-nauseates (antiemetics), laxatives and anti-anxiety. As of March 1, 2014, BCBSNC Blue Medicare members receiving hospice benefits will no longer be able to obtain their medications from a pharmacy under their Medicare Part D benefits. It is CMS guidance that all or substantially all medications are covered under the per diem payments made to hospice under Medicare Part A. 

Prior Authorization

In rare circumstances, if a hospice provider believes that a medication is completely unrelated to a hospice patient’s terminal or related condition(s), a prior authorization request may be submitted to the Medicare Part D plan that explains why these medications should be covered by Medicare Part D and not Medicare Part A. If the patient has discontinued hospice care, the hospice provider must advise CMS that the hospice election has ended. The plan will then receive a new report from Medicare notifying us of the change.

The hospice care provider or prescriber can contact BCBSNC’s Clinical Review Department at the appropriate number below to initiate a prior authorization request. Under CMS guidance, pharmacies should not initiate hospice prior authorizations.  

  • Blue Medicare HMO:  1-888-310-4110 or fax at 1-888-375-8836
  • Blue Medicare PPO:   1-877-494-7647 or fax at 1-888-446-8535
  • Blue Medicare Rx:        1-888-247-4142 or fax at 1-888-446-8440

For additional information regarding CMS’ recent clarifications about hospice (and end-stage renal disease) drugs, please see the related news item that was posted on February 6, 2014.