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

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.

Endo Pharmaceuticals to voluntarily withdraw Opana® ER

opana-er-85341864The FDA and the Endo International plc reached an agreement on July 6, 2017 to voluntarily withdraw its reformulated Opana® ER (oxymorphone HCL extended release tablets) from the market after determining the benefits of its use in patients no longer outweighs the misuse and abuse risks. Endo plans an orderly transition for patients to minimize treatment disruption and to ensure patients have time to work with their prescribers. Optum expects prescribers will review their patients’ current therapy, evaluate the continued need for ongoing opioid therapy and then choose their course of action. This new treatment plan may include either implementation of an opiate weaning schedule as a plan to discontinue opioid therapy for or to continue opioid therapy and begin the process of migration to a new medication. Should a claimant require continued opioid therapy, alternatives exist including a generic non-abuse deterrent formulation of oxymorphone extended-release tablets.

At this time, Optum highly recommends awaiting change of therapy to an alternative medication prior to submission of any Medicare Set Aside (MSA) to The Centers for Medicare and Medicaid Service (CMS) to avoid the possibility of inclusion of Opana® ER in the approved MSA. We are proactively reviewing previously completed (MSA) reports and current referrals and will notify clients whose MSA contains Opana® ER. This voluntary withdrawl provides an opportunity to help the prescriber in weaning or transitioning the claimant to another opioid regimen.

We offer a variety of clinical products and have a staff of pharmacists and nurses to assist claimants with a plan to render the most cost-effective treatment for the claimant while allowing for the best therapeutic outcome.

Note, at this point other formulations of Opana® will remain on the market; the only formulation slated for removal is the Opana® ER. Click here to view the Endo news release in reference to this matter.