PMSI Meets with CMS Regarding Prescription Drug Allocation Issues

On September 20, 2010, PMSI Settlement Solutions met with CMS to continue our dialogue around the pharmacy portion of MSA allocations. Our main focus during this meeting was to address inconsistencies we are all experiencing in the interpretation of the May 14, 2010 Memorandum regarding Part D covered prescription drugs. PMSI addressed inconsistencies concerning off-label prescription drug usage, the appropriate treatment duration for acute drugs, and the re-review process. For example, we highlighted inconsistencies across reviewers at the Workers’ Compensation Review Center (WCRC) regarding the exclusion of drugs like Lyrica, Gabapentin and Lidoderm. PMSI also requested that CMS issue a formal directive in regards to which compendia will be utilized during the review process. We highlighted the need for policies and procedures that would support the various policy memos.

CMS was extremely receptive to our feedback and willing to further investigate the issues facing the insurance industry surrounding drug allocations and the review process. CMS is considering retaining an independent consulting firm to help re-engineer the overall MSA review processes. The plan is for these consultants to meet with various industry participants to gain input into the process and challenges they face. We applauded this effort and offered any assistance which we could provide.

During our discussion, CMS mentioned that State Fee Schedules should be an acceptable means of pricing the pharmacy component—as long as the appropriate fee schedule is attached as back-up documentation. This would be a very welcome change and could give the industry some immediate relief. We hope to see a formal published announcement confirming this in the near future.

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