Medicare Part D Prior Authorization Procedure

Hospices are required by Medicare to pay for drugs that treat nausea, vomiting, anxiety, pain, and constipation along with those that are related to terminal diagnoses. Every once in a while there may be a situation where the hospice and the patient’s Part D plan disagree on what should be covered. This could happen in a couple of scenarios:

  1. A drug has multiple uses and the use in the hospice patient is not related to the terminal diagnosis. For example, the cardiac medication Terazosin is being used for benign prostatic hypertrophy (BPH) rather than to lower blood pressure (BP). So, it should not be covered in a cardiac patient because BPH is not related to cardiac issues.
  2. The medication would be a liability to the hospice agency. For example, the patient/family insists on an off-formulary, brand name Zofran (8mg orally disintegrating tablets, or ODT) at $1300 for 30 tabs rather than the on-formulary generic for $30.

In these situations, the hospice agency can fill out a “Hospice Information to Override and Hospice A3 Reject” form and fax it to the patient’s Part D plan, or call the Part D plan and a customer service representative can help them complete the form.

There are a few medications that are not covered under Medicare Part D Plans: OTC and prescription vitamins, OTC medications, and cough/cold relief medications.

The steps to complete the override form are as follows:

  1. Identify the Medicare Part D plan from patient’s card or by contacting the dispensing pharmacy.
  2. Call the Part D plan to obtain the correct fax number to send the form to the provider. Note: Some Part D plans have their own form; this may be a good time to ask which form is preferred or if the Medicare form is sufficient.
  3. Complete Section I, including “Purpose of the form.”
  4. Section II is optional; however, it may assist in the coordination of care.
  5. Sign and date the form.
  6. Fax the completed form to the Part D plan.
  7. Keep any and all documentation on file for audit purposes of why the medication is unrelated or a liability to the hospice.

If the form is completed correctly, overrides are granted within 24-72 hours. Additionally, Medicare suggests that hospices provide a “compassionate first fill” while the patient waits for approval so there is not a lapse in symptom management.

The override form is also used to report Notification of Enrollment (NOE) and Notification of Termination (NOTR) to hospice. The completed forms should also be sent to the patient’s Medicare Part D plan to prevent any lapse in services.

By | 2018-01-04T20:03:51+00:00 March 1st, 2017|Pharmacist Corner|0 Comments

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