Once you’ve elected Medicare hospice, the hospice benefit should cover any prescription drugs needed to control pain and manage the symptoms of your terminal condition.
- You pay nothing for prescription drugs you receive as an inpatient in a hospital or skilled nursing facility.
- For each prescription you get as an outpatient, your copay can be no more than $5.
Be aware that the hospice benefit will not cover medications that are not for pain relief and management of your terminal condition. If you are enrolled in a Medicare Part D, your Part D plan may cover medications that are unrelated to your terminal condition. This is true whether you have a Medicare Advantage Plan or a stand-alone Part D plan. Call your plan to find out if their list of drugs (formulary) includes your medication or if your prescription has any coverage restrictions. Part D coverage rules and costs will apply to medications that are not for pain management.
If you choose to end hospice care, provide your Part D plan written proof the change, so it can update your status in its systems. If you do not give your plan this information, you may get medication denials.
Be aware that Medicare assumes that medications prescribed to treat symptoms of pain, nausea, constipation, or anxiety are related to your terminal condition and should be covered by your hospice provider, not your Part D plan. However, sometimes, you may need these types of medications to treat illnesses unrelated to your terminal condition. To ensure Part D coverage of anti-nausea, anti-anxiety, laxative, and pain medications, it’s best to ask your hospice provider to send information to your Part D plan before you get them filled to indicate the prescriptions are unrelated to your terminal condition. After receiving this information, your Part D plan must cover the medication.
If you medication is denied at the pharmacy counter, you will receive a notice called the Medicare Prescription Drug Coverage and Your Rights Notice. To get your Part D plan to cover your prescriptions, contact them to request a formal decision called a coverage determination. Your plan must then contact your hospice provider or doctor for information indicating that the anti-nausea, anti-anxiety, pain or laxative mediation is unrelated to your terminal condition. Be sure to confirm with your hospice provider that the plan actually receives this information. The plan must then provide coverage within three days or within 24 hours if waiting longer places your health at risk. In the meantime, you can ask your hospice to cover a temporary supply of your medication under the hospice benefit.