What Does Generic Lyrica Mean for MSAs?

July 31, 2019

rubber stamp approving a prescription

On July 19, 2019, the Food and Drug Administration (FDA) approved multiple applications for the first generics of Lyrica (pregabalin). This follows the expiration of Pfizer’s patent on Lyrica at the end of June. The generic is expected to be available at pharmacies in the coming weeks.

 

Lyrica remains FDA approved for the following indications:

  • Diabetic peripheral neuropathy
  • Fibromyalgia
  • Neuropathic pain associated with spinal cord injury
  • Adjunct therapy for the treatment of partial-onset seizures
  • Postherpetic neuralgia

If a claimant is being prescribed Lyrica for any of the above indications and such indication is related to the workers’ compensation injury, then it will be included in the MSA. In workers’ compensation injuries, Lyrica is most frequently prescribed for neck or back pain. For years, CMS considered Lyrica non-Medicare-covered for neck or back pain unless such treatment stemmed from a traumatic spinal cord injury. However, CMS recently expanded its interpretation of what is considered a spinal cord injury, explaining in the updated WCMSA Reference Guide released this past January:

 

Lyrica is considered acceptable for pricing as a treatment for WCMSAs that include diagnoses related to radiculopathy because radiculopathy is a type of neuropathy related to peripheral nerve impingement caused by injury to the supporting structures of the spinal cord.

 

As a result, MSAs have included Lyrica more frequently.

 

Red Book currently prices brand-name Lyrica in the range of at $9.36 to $10.30 per pill depending upon the dosage. The MSA for a person taking Lyrica 50mg three times a day over a 20-year life expectancy would allocate $222,580 for the medication. Red Book shows a generic price range of $7.58 to $8.43 per pill depending on the dosage. While not a significant per-pill decrease, the generic switch over the 20-year life expectancy produces an allocation of $163,728 – a $58,752 reduction. The good news is with multiple manufacturers approved to sell the generic; we expect the per-pill price to drop even further.

 

Practical Questions

 

Will CMS automatically allocate the Lyrica in the MSA at the generic price?

 

As with any medication, including Lyrica, it is important to keep in mind that CMS will not automatically use the generic price when the treatment records and/or prescription history document brand name use. Instead, it must be proven to CMS typically, through prescription payment history, that the claimant has been switched to the generic. One fill documenting the switch to generic should be sufficient.

 

What is Tower doing for MSA referrals which include brand-name Lyrica?

 

If the claim prescription history documents brand Lyrica, we will advise you that a generic version of Lyrica has been approved and is or will soon be available.  Tower will show you the price difference between brand and generic and recommend working with the treating physician and your pharmacy benefit manager to make the switch.  If a statement from the treating physician is required to authorize the switch, Tower can obtain it from the physician (although we will still need prescription history documenting at least one fill of the generic).

 

If the MSA was previously approved by CMS with brand-name Lyrica can it be re-priced to generic?

 

CMS will not consider an MSA Re-Review or Amended Review based solely upon a prescription medication pricing change. An Amended Review MSA would need to document not only the switch to generic Lyrica but other changes as well, such as a previously allocated medication having been discontinued.

 

If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at (888) 331-4941 or daniel.anders@towermsa.com.

 

 

 

 

 

NAMSAP Provides Unique Opportunity to Expand Your Medicare Compliance Knowledge

July 29, 2019

banner for 2019 NAMSAP Educational Conference

Through our quarterly webinars and in-person trainings, Tower offers our partners recent and relevant information combined with best practices in Medicare Secondary Payer compliance. However, once a year, a unique opportunity is presented by the National Alliance of Medicare Set-Aside Professionals (NAMSAP) at its educational conference.

This annual conference, which is sponsored by Tower, brings together the best industry minds, including representatives from CMS and its contractors for presentations and discussions on the latest in Medicare compliance. It is designed for professionals who are involved in all aspects or any aspect of MSP compliance, such as, adjusters and managers and claimant and defense attorneys.

A wide spectrum of MSP and MSA topics will be presented, including reimagining the MSA Program, MSP policy activity, the current regulatory environment and recent case law. Notable conference panelists include John Albert, a Senior Technical Advisor from CMS’s Division of MSP Operations, Jim Brady, Program Director of the Benefits Coordination and Recovery Center (BCRC) and Rose Arellano, Director of Outreach Recovery for the Commercial Repayment Center (CRC)

The conference will be held at the recently reopened LIVE! Casino in Baltimore, Maryland, September 18-20. For early registration options and other information, go to NAMSAP.org

We encourage you to attend and expand your knowledge of MSP compliance. If you have any questions about the conference, please contact Dan Anders at daniel.anders@towermsa.com or (888) 331-4941.

 

 

METRICS, MSAS & SETTLEMENT STRATEGIES AT WCI2019

July 26, 2019

Tower’s Dan Anders and American Airline’s Kris Sallee will present during two panels at the Workers’ Compensation Institute (WCI) Workers’ Compensation Educational Conference (WCI2019) this year.

Starting at 9 a.m. on Aug. 14, “Optimizing Settlement Outcomes by Measuring and Managing MSA Costs” stresses the importance of determining and using metrics to evaluate and improve your MSA program. The session will be moderated by Michael Stack, CEO of AMAXX, and Kris and Dan will also describe how clinical interventions produce MSAs that balance care, cost, and compliance. Then at 10:15, “Allaying the MSA Fear at Time of Settlement” Ametros CEO Marques Torbert and Structured Settlement Consultant Joe Bornstein join the panel to examine reasons employers and injured workers avoid settling claims.

For more information, see Tower MSA Partners’ Dan Anders to Discuss Metrics for MSAs and Claims Settlement Strategies at WCI 2019.

WCI2019 will be held August 11-14, 2019.

Everything You Wanted To Know About MSAs, But Were Afraid To Ask — Tower Premier Webinar – July 24, 2019 2PM ET

July 2, 2019

banner for 2019 tower msa partners webinar details

Why does CMS do what they do when it comes to MSAs? Many a claims professional and injured worker have probably pondered this question. Well, the wait for answers is over. On July 24, 2019 at 2 pm ET, Tower MSA Partners EVP of Clinical Services Patricia Smith and Chief Compliance Officer Dan Anders host an engaging hour-long webinar discussing all matters MSA.

 

With over 30 years of MSA experience between them, Pat and Dan will tackle some of the routine and unusual questions that arise when drafting an MSA and submitting it to CMS for approval, like:

 

  • Do I need an MSA?
  • What documentation is necessary to draft the MSA?
  • What does Medicare-covered or not Medicare-covered mean to the MSA?
  • Is the allocation different if the MSA isn’t submitted to CMS?
  • How are costs of treatment and prescription medication calculated?
  • How is life expectancy calculated and how does a rated age impact this calculation?
  • IMEs, AMEs, PQMEs, UR, and IMRs, oh my. What role do these play in the MSA calculation?
  • Rechargeable vs. non-rechargeable spinal cord stimulator, why does it matter?
  • When can I use an Amended Review?
  • Under what circumstances is a $0 MSA appropriate?

 

If you want to know more about the how and why of MSAs, this free webinar is for you. And, if there is something about MSAs you’ve always wondered about, ask us! When you click on the registration link below you will not only be able to register, but you can also submit a question to be answered during the webinar.

 

Hope you can join us on July 24 at 2 pm ET!

 

Dan Anders

 

Chief Compliance Officer

 

Register Here