Author Archives: Evelio Prieto, PharmD., RPh., CPh.

About Evelio Prieto, PharmD., RPh., CPh.

Evelio Prieto is a pharmacist and consultant pharmacist registered in the state of Florida. He is a graduate of the University of Florida College of Pharmacy where he earned a Doctor of Pharmacy degree in 1994. Evelio has worked as a pharmacist at Optum Settlement Solutions for four years. Prior to Optum, Evelio managed two local hospital outpatient and ambulatory infusion pharmacies (Tampa General Hospital and All Children’s Hospital John’s Hopkins Medicine). Prior to this, Evelio spent 15 years managing a Walgreens pharmacy. Throughout his career, he has worked with worker’s compensation and managed care Pharmacy Benefit Managers (PBMs) as well as Medicare Part B and D billing to ensure care for claimants in the community. Evelio served on the Florida Medicaid Drug Utilization Review Board from 2010 to 2015 and is part Optum’s Clinical Center of Excellence.

The Optum Clinical Team Can Help You Move Your Claims to Settlement

It is common for medications to comprise a large proportion of a Workers’ Compensation Medicare Set-Aside (WCMSA) allocation. Often times the cost of prescription medications can drive up claim costs and prohibit settlement. Clinical interventions that both improve the injured worker’s medication regimen and aid in decreasing costs are tools that Optum provides to assist our clients. Part of our approach is monitoring RED BOOK® Average Wholesale Price (AWP) for the most common medications present in (WCMSA) arrangements. Through this process, we identify price adjustments which positively or negatively affect the WCMSA.

In the month of July we saw price increases for Vesicare® tablets (used in the treatment of bladder conditions) and Gralise® tablets (gabapentin extended release for neuropathic pain). There was a price decrease for hydromorphone extended release tablets (long-acting opioid for chronic pain).

The products in the table below have a change in AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product name NDC code Dosage form

Strength

AWP unit price
reduction/increase
Hydromorphone 13811070110 ER Tablets

8 mg

-$5.85

Hydromorphone 13811070210 ER Tablets

12 mg

-$7.20

Hydromorphone 13811070310 ER Tablets

16 mg

-$9.60

Hydromorphone 13811070410 ER Tablets

32 mg

-$19.20

Gralise 13913000419 Tablets

300 mg

$0.92

Gralise 13913000519 Tablets

600 mg

$0.92

Vesicare 51248015052 Tablets

5 mg

$0.82

Vesicare 51248015103 Tablets

10 mg

$0.82

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

CMS uses the lowest AWP when reviewing a WCMSA. If you have a WCMSA with hydromorphone ER tablets you will immediately benefit from a reduction in the cost of this medication. In some cases, this may make settlement a viable option.

Optum will proactively contact clients when we have previously completed a WCMSA where these medications are prescribed. It is our recommendation that carriers, TPA’s and claim handlers review cases to determine if price changes positively impact settlement options.

Optum has clinical intervention products available, which may help mitigate costs and improve patient outcomes through more suitable clinical alternatives and cost effective therapeutic equivalents. We will continue to inform the industry of AWP pricing and other changes that may affect WCMSA arrangements.

Prescription drug price updates that may affect Medicare Set Asides

To ensure the most accurate Workers’ Compensation Medicare Set-Aside (WCMSA) arrangement, we monitor RED BOOK® Average Wholesale Price (AWP) of the most common medications present in WCMSAs. This practice assists in identifying price changes, which may either positively affect settlement and provide savings, or increases that could hinder the settlement process and increase claims costs.

In the month of June, there were price changes for morphine sulfate tablets – both immediate release and extended release—brands MS Contin and Dilaudid, opioids commonly used for chronic pain. Products with price increases are relatively insignificant at less than 10 percent. However, the decreases are greater than 50 percent, and could provide savings on cases where these medications are prescribed.

The following products in the table have a change in AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Drug Name

NDC

Form

Strength

AWP Unit Price Change

Morphine Sulfate

42858-0801-01

ER Tablets

15mg

-$0.67

Morphine Sulfate

42858-0802-01

ER Tablets

30mg

-$1.48

Morphine Sulfate

42858-0803-01

ER Tablets

60mg

-$2.48

Morphine Sulfate

42858-0804-01

ER Tablets

100mg

-$2.09

Morphine Sulfate

00054-0235-25

Tablets

15mg

$0.08

Morphine Sulfate

00054-0236-25

Tablets

100mg

$0.14

MS Contin

42858-0515-01

ER Tablets

15mg

$0.43

MS Contin

42858-0631-01

ER Tablets

30mg

$0.82

MS Contin

42858-0760-01

ER Tablets

60mg

$1.61

MS Contin

42858-0799-01

ER Tablets

100mg

$2.38

Dilaudid

42858-0122-01

Tablets

2mg

$0.24

Dilaudid

42858-0122-01

Tablets

4mg

$0.37

Dilaudid

42858-0338-01

Tablets

8mg

$0.71

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

CMS uses the lowest AWP when reviewing WCMSA arrangements. The changes in price of these medications will immediately affect the prescription costs of WCMSA’s (both present as well as prior WCMSA’s that have not settled and there is no CMS determination issued). Optum will proactively contact clients when we have previously completed a WCMSA if we identify a significant impact to a case. It is our recommendation that carriers, TPA’s and claim handlers review their open cases to determine the affect these price changes may have on each individual claim.

If a price increase will adversely affect your case and preclude settlement, Optum has clinical mitigation products available to assist with lowering claim costs and aid in the settlement process.

Optum will continue to inform the industry of AWP pricing and other changes that may affect WCMSA arrangements.

U.S. Food and Drug Administration approves Aimovig™

On May 17, 2018, the U.S. Food and Drug Administration (FDA) approved Aimovig™ (erenumab-aooe) for the preventive treatment of migraines in adults. Aimovig (erenumab-aooe) is the first FDA approved drug in a new class of drugs that are classified as calcitonin gene-related peptide receptor blockers. The calcitonin gene related peptide receptor (CGRP-R) is associated with migraine headache. This new agent aids in reducing the number of headache days a month.

Aimovig was approved for the preventative treatment of migraines in adults based on evidence of three placebo controlled clinical trials. More than 3,000 patients participated in the efficacy and safety tests. Between the three studies, patients experienced one to two and one-half fewer migraines per month as compared to placebo. The most common side effects reported in clinical trials were injection site reactions and constipation. The discontinuation rate is listed at two percent. Ongoing open label extension studies will continue for up to five years.

Aimovig, developed in partnership by Novartis Pharmaceuticals and Amgen, Inc., is expected on the market in a week. Aimovig is administered once monthly by self-injection in either a 70 mg or a 140 mg dose. The U.S. list price according to Novartis is $575.00 for a once monthly 70 mg or 140 mg self-administered injection ($6,900 annually). The Redbook average wholesale price (AWP) pricing is not yet published. The pricing of Aimovig is comparable to the cost of botulinum toxin (Botox) 200 units every three months with an annual cost of $5,768. This cost does not include the in-office Botox administration provider fee. Botox is FDA approved for chronic migraine prophylaxis.

With the commonality of migraine headaches in workers’ compensation and liability claims, adjusters are likely to see the use of this medication in the near future. We expect that, similar to the criteria of botulinum toxin for prevention of chronic migraine, Aimovig users will have failed more conservative first line therapy (amitriptyline, beta-blockers, topiramate and valproic acid derivatives). At this time, there is no evidence for the use of botulinum toxin and Aimovig for chronic migraine prevention.

Optum will provide updates as new medications enter the marketplace as well as details on their impact on settlements.

View highlights of prescribing information here.

Additional sources:

  1. FDA approves new drug for preventive treatment of migraine in adults- Drug Information Update Available at: Aimovig Accessed May 18, 2018.
  2. Novartis and Amgen announce FDA approval of Aimovig™ (erenumab-aooe), a novel treatment developed specifically for migraine prevention. Available at: https://www.prnewswire.com/news-releases/novartis-and-amgen-announce-fda-approval-of-aimovig-erenumab-aooe-a-novel-treatment-developed-specifically-for-migraine-prevention-300650779.html. Accessed May 18, 2018.
  3. The Workloss Data Institute. The Official Disability Guidelines (ODG). http://www.disabilitydurations.com/. Accessed May 2018.

Prescription Medication Updates That May Affect Your Medicare Set-Aside

We continually monitor pricing of the most common medications seen in Workers’ Compensation Medicare Set-Aides (WCMSAs) in order to identify pricing changes affecting MSAs positively. The month of December brought a price drop for gabapentin 800mg tablets commonly used to treat neuropathic pain.

Below is the product confirmed to have 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
Gabapentin 00904-6586-61 TAB 800 mg $2.16

Please note RED BOOK® AWP (Average wholesale price) is subject to change and this pricing is subject to an increase or decrease in the future.  

CMS will utilize the lowest AWP published by RED BOOK 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 WCMSAs 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 medication is prescribed to determine the benefit from decreased cost. We will proactively reach out to our clients in reference to previously completed WCMSA’s where this medication was prescribed and  continue to monitor future portal changes and generic equivalents introduced to the market in order to keep the industry informed.