June 2, 2009, CMS Prescription Drug Set-Aside Guidance for Submitters
http://www.cms.hhs.gov/WorkersCompAgencyServices/Downloads/WCMSARXGuid [...]
On June 2, 2009, the Centers for Medicare and Medicaid Services set forth published guidelines detailing prescription drug policies for MSA submitters, effective June 1, 2009.
In general, the CMS Prescription Drug Set-Aside Guidance for Submitters publication states the following:
• Pricing is to be based on the most current REDBOOK® Drug Reference
• CMS will use the lowest priced generic drug listed in the REDBOOK® Drug Reference
• Allocations are to include prescriptions “reasonably and probably predictable” in the future, based on the assumption the Claimant is at Maximum Medical Improvement
• Tapering will be considered by CMS
• Off-label use does not preclude those prescriptions from the allocation
• Utilizations reviews will be considered, but reports of actual drug use from treating physicians will be given more weight than utilization reviews
• Generic pricing may only be used for generics that exist
• Failure to submit prescriptions results in Medicare’s use of brand name pricing
• Submitters are encouraged to present any evidence helpful towards a determination
While Medicare’s publication is vague as to how tapering will be reviewed, it does mention that actual tapering and a treating physician’s belief that tapering is possible and in the best interest of the Claimant will be factors to consider. The memo does not clarify what other factors, if any, Medicare will consider in determining whether future tapering is anticipated.
Medicare’s publication emphasizes that the CMS and the WCRC will review evidence on a case-by-case basis in their prescription drug allocation decisions. Because of this, it is more important now than ever that your Medicare Set-Aside provider has the proper medical and legal skills necessary to craft persuasive allocations that highlight the best evidence available in the submissions of MSAs to CMS for approval. Burns White's Medicare Set-Aside group has nurses and attorneys on staff preparing Medicare Set-Asides, utilizing their combined professional expertise. Burns, White & Hickton has a history of preparing MSAs as an advocate, always making arguments when available to serve the needs of our clients.
Please contact Bruce McKnight with any questions at (412) 995-3247.
On June 2, 2009, the Centers for Medicare and Medicaid Services set forth published guidelines detailing prescription drug policies for MSA submitters, effective June 1, 2009.
In general, the CMS Prescription Drug Set-Aside Guidance for Submitters publication states the following:
• Pricing is to be based on the most current REDBOOK® Drug Reference
• CMS will use the lowest priced generic drug listed in the REDBOOK® Drug Reference
• Allocations are to include prescriptions “reasonably and probably predictable” in the future, based on the assumption the Claimant is at Maximum Medical Improvement
• Tapering will be considered by CMS
• Off-label use does not preclude those prescriptions from the allocation
• Utilizations reviews will be considered, but reports of actual drug use from treating physicians will be given more weight than utilization reviews
• Generic pricing may only be used for generics that exist
• Failure to submit prescriptions results in Medicare’s use of brand name pricing
• Submitters are encouraged to present any evidence helpful towards a determination
While Medicare’s publication is vague as to how tapering will be reviewed, it does mention that actual tapering and a treating physician’s belief that tapering is possible and in the best interest of the Claimant will be factors to consider. The memo does not clarify what other factors, if any, Medicare will consider in determining whether future tapering is anticipated.
Medicare’s publication emphasizes that the CMS and the WCRC will review evidence on a case-by-case basis in their prescription drug allocation decisions. Because of this, it is more important now than ever that your Medicare Set-Aside provider has the proper medical and legal skills necessary to craft persuasive allocations that highlight the best evidence available in the submissions of MSAs to CMS for approval. Burns White's Medicare Set-Aside group has nurses and attorneys on staff preparing Medicare Set-Asides, utilizing their combined professional expertise. Burns, White & Hickton has a history of preparing MSAs as an advocate, always making arguments when available to serve the needs of our clients.
Please contact Bruce McKnight with any questions at (412) 995-3247.
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