So the buzz is around the office today about new Medicare Part D changes that are going to majorly and adversely affect patients and their families, and also be the death knell for hospices throughout the country.
See the following link for the actual final determination and new rules that are supposed to be effective May 1, 2014:
The Readers' Digest version of this new policy is that patients, once enrolled onto hospice services, will only be covered for medications directly related to the palliation and symptom management of their illness. In example, Sally Jones is admitted to hospice with a Dx: Cervical Cancer. Medicare will now only cover medications directly related to this illness (e.g. Analgesics, Anti-Emetics, Laxatives/Stool Softeners, Anti-Anxiety). But if Sally Jones also suffers from COPD and is also s/p CABG, medications related to those diagnoses will no longer be covered under Medicare Part D and will become the liability of the patient or the hospice provider if they so choose to cover the medications.
So what this means is that hospice patients facing terminal illness for one problem may very well become at greater risk secondary to other comorbidities than their primary diagnosis. Additionally, this will add financial stressors to families already dealing with terminal illness. Coupled with the cuts already hitting hospice providers last year, this is surely going to sink some hospices altogether. And we'e already seeing patients getting their rejection notices for medications two months ahead of this change being implemented.
I'm curious to know thoughts on this. Is this buzzing within your own work culture? Better freshen up those resumes, ladies and gents, because this could be a game changer.
Cymbalta IS NOT covered under Part D. I spent a nice chunk of my day yesterday speaking with pharmacists (hospice & public). Part D said NO. The pt was switched to a hospice formulary antidepressant. Now, no I did not attempt to get PA because Medicare says Part D will only cover unrelated meds for hospice pts in those "rare & unusual circumstances" (likely insulin & such). I didn't feel needing cymbalta was rare/unusual.
I'm still not sure where this is coming from. Cymbalta, AKA duloxetine, is still part of the part D formulary as a generic (it's the same drug just without the fancy commercials).
What makes you say that? Why would CMS desire to have a few hospices fail for reasons other than fraud?
"Hospice has been a good business." Too good. Too many start ups falling over themselves to get in while the gettin' was good. What other business could one start and not experience the traditionally high new business start-up failure rate? Probably none. Of course that will change now.
And there's a host of other reasons like more hospice agencies making it more difficult and expensive for CMS to track compliance, do audits, etc.
I'm still not sure where this is coming from. Cymbalta, AKA duloxetine, is still part of the part D formulary as a generic (it's the same drug just without the fancy commercials).
Because part D is not covering symptom mgmt medications bc they feel part A (hospice) should cover. Doesn't matter if it's formulary for Part D.
In my case the brand/generic is NOT hospice formulary. The ONLY option is for pt to pay out of pocket or accept an equivalent hospice formulary med.
Because part D is not covering symptom mgmt medications bc they feel part A (hospice) should cover. Doesn't matter if it's formulary for Part D.
In my case the brand/generic is NOT hospice formulary. The ONLY option is for pt to pay out of pocket or accept an equivalent hospice formulary med.
If the medications are to treat symptoms related to the hospice diagnosis then of course hospice should be paying for them, that's been part of the deal for a long time now.
If the medications are to treat symptoms related to the hospice diagnosis then of course hospice should be paying for them, that's been part of the deal for a long time now.
Yes, that's right. Now Part D won't be covering unrelated meds without prior authorization.
So why do you feel cymbalta (or generic) would be covered under part D then? I don't see Medicare D giving PA for an antidepressant. Insulin, probably.
Yes, that's right. Now Part D won't be covering unrelated meds without prior authorization.
So why do you feel cymbalta (or generic) would be covered under part D then? I don't see Medicare D giving PA for an antidepressant. Insulin, probably.
Why do you think it wouldn't be covered under part D?
Why do you think it wouldn't be covered under part D?
As I have stated in several responses.........
Part D expects PART A to cover symptom related medications. Part D will no longer cover ANY meds for hospice pts without prior authorization. As Medicare states, for part D to cover any meds it must be a "rare and unusual circumstance"
covering an antidepressant for a hospice pt is not going to be RARE OR UNUSUAL. Part D expects Part A to cover. If that particular medication is not formulary for the hospice (cymbalta), then a formulary equivalent antidepressant can be prescribed or the pt can pay out of pocket.
Specializes in NICU, PICU, Transport, L&D, Hospice.
In the example of anti-depressants, I believe that part of the problem is that depression is a common and expected diagnosis in terminal patients. Depression goes hand in hand with many chronic disease states which result in hospice referrals.
Determining which came first is often more of a chicken/egg exercise than anything else.
Most hospices I have worked with simply included that diagnosis and medication POC into the hospice POC. The only hospice that I have worked with that did NOT cover these meds in that fashion was a for-profit privately owned organization.
Part D expects PART A to cover symptom related medications. Part D will no longer cover ANY meds for hospice pts without prior authorization. As Medicare states, for part D to cover any meds it must be a "rare and unusual circumstance"
covering an antidepressant for a hospice pt is not going to be RARE OR UNUSUAL. Part D expects Part A to cover. If that particular medication is not formulary for the hospice (cymbalta), then a formulary equivalent antidepressant can be prescribed or the pt can pay out of pocket.
What you seem to be saying is that the need for antidepressents is often related to a terminal diagnosis, which means it must be included in hospice's part A reimbursement.
Continuing other meds while on hospice should be rare and unusual, they're on hospice. There are a few exceptions, but the most common drugs, such as statins, should be D/C'd on admission to hospice.
If cymbalta isn't part of hospice's formulary then that is the fault of the hospice, not medicare. I would disagree that the patient should have to pay out of pocket if a medication necessary related to their terminal diagnosis is not part of the hospice formulary, it's still the hospice's obligation to provide the medication; they're getting paid to provide all medications necessary related to the terminal diagnosis, having an excessively limited formulary to save money at the expense of denying patients medications they are obligated to provide wouldn't seem to be an acceptable business practice.
If cymbalta isn't part of hospice's formulary then that is the fault of the hospice, not medicare. I would disagree that the patient should have to pay out of pocket if a medication necessary related to their terminal diagnosis is not part of the hospice formulary, it's still the hospice's obligation to provide the medication; they're getting paid to provide all medications necessary related to the terminal diagnosis, having an excessively limited formulary to save money at the expense of denying patients medications they are obligated to provide wouldn't seem to be an acceptable business practice.
Although it will be less often, there'll still be cases where the patient may have to pay out of pocket. The patient has to be willing to play ball. If the patient refuses to try hospice formulary meds first then the patient will assume financial liability to cover that med as the Medicare D sponsor will also not cover it.
Although it will be less often, there'll still be cases where the patient may have to pay out of pocket. The patient has to be willing to play ball. If the patient refuses to try hospice formulary meds first then the patient will assume financial liability to cover that med as the Medicare D sponsor will also not cover it.
I agree that patients should be expected to use hospice formulary alternatives, but there needs to be alternatives which doesn't appear to be the case in the previous posts: ("the alternative needs to paid for out of pocket"), which would imply the hospice offers no alternatives as formulary. If that's a legitimate option it wouldn't make any sense for a hospice to have any meds in their formulary, which would save them a lot of money.
I agree that patients should be expected to use hospice formulary alternatives, but there needs to be alternatives which doesn't appear to be the case in the previous posts: ("the alternative needs to paid for out of pocket"), which would imply the hospice offers no alternatives as formulary. If that's a legitimate option it wouldn't make any sense for a hospice to have any meds in their formulary, which would save them a lot of money.
You misunderstood if you interpreted my post to mean the pt has to pay out of pocket for a HOSPICE FORMULARY EQUIVALENT. hospice covers ALL formulary meds 100%. If the Pt refuses to try a formulary alternative, then the pt has the right to pay out of pocket.
In speaking towards an earlier post....yes, at times we have pts who have been treated for depression for years & years prior to hospice. Some hospice companies argue its not their responsibility to cover bc has been long term. I disagree. This exact attitude is why Part D is no longer willing to cover unrelated meds without PA.
MunoRN, RN
8,058 Posts
I'm still not sure where this is coming from. Cymbalta, AKA duloxetine, is still part of the part D formulary as a generic (it's the same drug just without the fancy commercials).