Tag Archive for: Prescription Drugs


CMS Allows Entry of Prescription Information Online

The Centers for Medicare and Medicaid Services (CMS) has announced an upcoming enhancement to its Medicare Set-Aside (MSA) Portal that will allow submitters to be able to enter prescription drug information directly to CMS online. Slated to begin on October 6, 2014, this new feature will:

  • Allow MSA submitters to indicate if a claimant is taking, or is expected to take prescription drugs as a result of a workers’ compensation injury, and to select those specific drugs through a lookup feature and add case specific information
  • Display the following information about those drugs: drug name, dosage, National Drug Code (NDC), price per unit and the number of years based on life expectancy
  • Calculate the expected drug cost using the monthly Redbook Drug Reference price that is in effect at the date of submission

CMS said that they will publish another alert prior to implementation with more detailed information. We will provide that info on this blog as soon as it is released.

To view the CMS announcement click here.


CMS Offers Prescription Drug Set-Aside Guidance

The Centers for Medicare and Medicaid Services (CMS) has released an interesting document to address the many questions that have been raised from their April 3, 2009 memo regarding the pharmacy review of submitted MSAs. In this latest document, CMS provides eight main points of clarification:

  1. Source for Evaluating Drug Component – The Workers’ Compensation Review Contractor (WCRC) will use the Red Book® Drug References to evaluate the sufficiency of the drug component of a Workers Compensation Medicare Set-Asides (WCMSAs).
  2. Documentation – CMS stresses that it is “imperative that submitters furnish accurate, complete, legible, and current medical and prescription records for the last two years…”. They also explain why it is their preference that WCMSAs only be submitted after the claimant has reached maximum medical improvement (MMI) and future drug needs be “reasonable, probable and predictable”.
  3. Tapering of Use – CMS will consider all evidence presented where a treating physician believes that tapering is in the best interest of the claimant.
  4. Expiration of Patent – All evidence submitted will be considered by CMS regarding whether or not a change to a less expensive drug is warranted at the expiration of a patent.
  5. Off-label Use – CMS acknowledges that physicians are free to prescribe an FDA-approved drug for any purpose that is safe and effective, but provides no further guidance as to how they will apply this concept in evaluating WCMSAs except in their conclusion below where they emphasize that they will consider all evidence submitted.
  6. Utilization Review – Utilization reports showing that the claimant should be taking more, different, less frequent or even no drugs will be considered, but more weight will be given to reports of actual drug use from treating physicians.
  7. Brand or Generic – CMS has confirmed their position on brand v. generic drugs. This document again states that where drugs are known to be needed and the submitter has not priced drugs, or the submitter has priced for a generic drug when a generic is not available, CMS will compare the WCMSA proposal to the average wholesale price for brand name drugs. They also state that if drugs are indicated on the proposal but the records do not specify whether the injured party is taking a generic or a brand name drug when both versions exist, CMS will compare the WCMSA proposal to the generic drug where the submitter has proposed a generic drug, and CMS will compare the WCMSA proposal to the brand name drug where the submitter has proposed a brand name drug or has not proposed a drug at all.
  8. Multiple Manufacturers – In the event that the WCMSA submission does not include supporting documentation regarding prices from multiple generic drug manufacturers, CMS will compare generic drugs in the WCMSA proposal and use the lowest priced generic drug as listed in the Red Book Drug References® in accordance with the April 3, 2009 procedure memo.

In conclusion, CMS emphasizes and encourages submitters to present any and all evidence they believe is helpful and CMS will review and consider all documents submitted.

To view this document in its entirety, please click here.


CMS to Review Pharmacy Portion of MSA

On April 6, 2009, The Center for Medicare and Medicaid Services (CMS) announced its preferred method of pricing the future prescription costs in a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) proposal. Effective June 1, 2009, CMS will begin independently pricing the future prescription costs of these proposals using Average Wholesale Price (AWP). The memo goes onto state that they “will not use or recognize any other pricing, discounting, or calculation methods when determining the adequacy of the prescription drug amounts in WCMSA proposals.”

This memo also states that if future prescription costs are not included in the WCMSA proposal, but the Coordination of Benefits (COB) contractor deems that future prescriptions are necessary, CMS will utilize AWP for brand name drugs when determining the sufficiency of the prescription drug amount. Also, if a proposal if priced according to “generic” pricing and the COB determines that a “generic” drug is not available, the proposal will be re-priced using brand name pricing.

While this latest memo does not specifically come out and say it, one is now lead to the conclusion that CMS will now be reviewing the future prescription costs on WCMSA proposals. This move appears to have put to rest the sometimes heated debate regarding the “donut hole” within WCMSAs. Previously there were some who felt that the Medicare Part D deductibles, the donut hole, should be taken out of WCMSAs. There were others who felt it was a direct violation of the Medicare Secondary Payer statute to do so, and subsequently did not account for the donut hole within their specific proposals. What we can all agree on is that CMS left the window open for debate since they were not reviewing the future prescription costs of a WCMSA proposal anyway. Whatever position one may have taken on that issue, it is now clear that CMS has closed the window and will now be reviewing the WCMSA proposals in their entirety.

To view this latest memo in its entirety, please click here.