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.
On June 8, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a policy memorandum regarding Rated Age (RA) language inclusion in Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) by submitters. The memo clarifies initial instructions regarding RA language outlined in a prior memorandum dated May 14, 2010, which required the following all-encompassing exact statement by submitters in regard to RAs:
“Our organization certifies that all rated ages obtained on the claimant, at any time during that individual claimant’s lifetime, have been included as part of this submission to the Centers for Medicare & Medicaid Services.”