New Commercial Repayment Center (CRC) contract awarded

Performant Financial Corporation announced on October 5, 2017, they were awarded the Medicare Secondary Payer Commercial Repayment Center (CRC) contract by the Centers for Medicare & Medicaid Services (CMS). Performant will succeed CGI Federal, the current contractor.

Performant is a leader in the identification and recovery of improper payments in the health care, government and student loan industries; Further, it will be Performant’s responsibility to identify and recover payments in situations where Medicare should not be the primary payer of health care claims when a beneficiary has other forms of insurance coverage, such as employer Group Health Plan or other certain other payers.

Congratulations, Performant, and we look forward to working with you.

Prescription medication updates that may affect your Medicare Set Aside

We continually monitor RED BOOK® Average Wholesale Price (AWP) of the most common medications seen in Workers’ Compensation Medicare Set-Aides (WCMSA) in order to identify pricing changes affecting MSAs positively. The month of September brought additional price drops for the medication quetiapine fumarate (Seroquel®), in 100mg and 300mg tablets, commonly prescribed to treat bi-polar disorder.

Below are the products we have identified with a reduced AWP and confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product name

NDC Code

Dosage form

Strength

AWP unit price reduction

Quetiapine Fumarate

00904-6640-61

TAB

100 mg

$5.89

Quetiapine Fumarate

00904-6642-61

TAB

300 mg

$9.60

Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.

CMS will utilize the lowest AWP when reviewing a WCMSA, therefore the lower pricing of these medications will immediately impact the prescription costs for WCMSAs (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued) where these drugs are prescribed.

It is our recommendation carriers, TPAs and claim handlers review cases where the above noted medications are prescribed to determine the benefit from decreased cost. We will proactively reach out to our clients in reference to previously completed WCMSA’s where these medications were prescribed and continue to monitor future AWP changes and generic equivalents introduced to the market in order to keep the industry informed.

Prescription Drug Updates that may affect your Medicare Set Aside

We continually monitor RED BOOK® Average Wholesale Price (AWP) of the most common drugs seen in Workers’ Compensation Medicare Set-Aides (WCMSA) in order to identify pricing changes affecting MSAs positively. The month of August brought price drops for the medications quetiapine (Seroquel®), in multiple strengths, commonly prescribed to treat bi-polar disorder and lansoprazole (Prevacid®) 30mg a Proton-Pump Inhibitor, used to treat stomach ulcers, gastro esophageal reflux disease (GERD) and high levels of stomach acid.

Below are the products Optum identified with a reduced AWP and confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product Name NDC Code Dosage Form Strength AWP Unit Price Reduction
Quetiapine Fumarate 00904-6638-61 TAB 25 mg $0.04
Quetiapine Fumarate 00310-8280-60 TER 50 mg $8.01
Quetiapine Fumarate 00310-8281-60 TER 150 mg $14.98
Quetiapine Fumarate 00310-8282-60 TER 200 mg $16.46
Quetiapine Fumarate 00310-8283-60 TER 300 mg $21.75
Quetiapine Fumarate 00310-8284-60 TER 400 mg $25.63
Lansoprazole 70700-0263-05 ECC 30 mg $1.60

Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.

CMS will utilize the lowest AWP when reviewing a WCMSA, therefore the lower pricing of these medications will immediately impact the prescription costs for WCMSAs (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued) where these drugs are prescribed.

It is our recommendation that carriers, TPAs and claim handlers review cases where the above noted medications are prescribed to determine the benefit from decreased cost. We will proactively reach out to our clients in reference to previously completed WCMSA’s where these medications were prescribed.

Another change occurring is the generic availability of Relpax® tablets (eletriptan hbr tablets) in 20mg and 40mg. This new generic offers an 11 percent decrease in AWP price. As more manufacturers bring generics for Relpax to market, we expect the price to decrease even more over the next year.

We previously identified pricing changes for several other drugs recently, such as carisoprodol, aripiprazole and esomeprale providing significant MSA savings for clients on cases not settled or approved by CMS. We will continue to monitor future AWP changes and generic equivalents introduced to the market and will keep the industry informed.

New Workers’ Compensation Review Contractor (WCRC) contract awarded

Capitol Bridge, LLC has been named the new Workers’ Compensation Review Contractor (WCRC) effective September 1, 2017, succeeding Provider Resources. Capitol Bridge is a Government Services firm headquartered in the Washington Metropolitan area with offices in Arlington, Virginia, Washington, D.C., and Columbia, Maryland.

Congratulations to Capitol Bridge and we look forward to working with you.