With prescription prices increasing every day, it’s harder than ever to contain costs. That’s why we put together three easy ways to reduce Workers’ Compensation Medicare Set-Aside (WCMSA) costs.
1. Split the difference on dosages
Splitting higher dosages into multiple lower dosages can really cut costs. Take gabapentin, the generic form of Neurontin. Often prescribed for nerve pain, the drug comes in 100mg, 300mg, 400mg, 600mg, and 800mg pills. If the patient takes a 600mg or 800mg dose, consider asking the prescribing physician (if permitted in your jurisdiction) to prescribe two 300mg or 400mg pills instead.
Savings: The lowest current average wholesale price (AWP) cost of a 600mg to 300mg pill drops from $2.28 to $.03 per pill, while the 800mg to 400mg drops from $2.87 to $.22 per pill. ISO Claims Partners saved our client nearly $50,000 by working with the adjuster to modify the gabapentin dosage, and prevented a possible counter higher of over $100,000 in the process.
2. Two pills may be better than one
Pharmaceutical firms sometimes combine two medications in a single drug—but the costs can be much higher. For example, DUEXIS is an expensive pill that combines famotidine and ibuprofen, which, on their own, are much less costly. If jurisdictional rules allow, see if the prescribing physician will replace DUEXIS with separate prescriptions for famotidine and ibuprofen.
Savings: The DUEXIS AWP cost is $30.12 a pill. However, the AWP costs per unit for famotidine (10mg is $0.19; 20mg is $1.51; and 40mg is $3.27) and ibuprofen (800mg is $0.28) are much more reasonable. ISO Claims Partners saved our client more than $308,000 by working with the adjuster to determine that DUEXIS was no longer prescribed.
3. Watch out for limited medical use
Adjusters need to watch out for this one: a medication that has a limited use being put into the WCMSA for recurring dosages that may not be necessary. Take Evzio, a self-treatment for opioid overdose. Physicians may prescribe Evzio, or some other type of naloxone, as a preventive measure when prescribing opioids to treat chronic pain. Because the Centers for Medicare and Medicaid Services (CMS) tends to include medications at the current prescribed frequency for the life expectancy of the claimant, annual doses of Evzio may show up in a WCMSA. This can be a high cost driver for a medication with limited, specific use.
Depending on the facts of the case, we believe adjusters can often argue that inclusion of Evzio in a WCMSA should be reduced. If a claimant has no history of opioid abuse or likely overdose, it’s valid to argue that it’s not “reasonably probable” that the claimant will need Evzio—or if it is needed, that it should be limited to one unit over the claimant’s life expectancy.
Savings: Evzio is currently priced at $5,626.00 or $6,150.00 per unit. ISO Claims Partners saved our client more than $129,000 when we worked with a doctor to determine Evzio should no longer be prescribed.
Putting it all together
Remember, it’s critical to combine these strategies with supporting physician documentation, especially when you submit the WCMSA to CMS. The agency requires written evidence—ideally a signed, dated letter on the physician’s stationery—before accepting treatment changes. It’s critical both to check your state jurisdictional requirements and to plan ahead to get the documentation you need.
We hope these strategies help you reduce WCMSA costs in your cases. And remember, we at ISO Claims Partners are here for you—and we will carefully comb through each assignment to help our customers identify valuable cost savings.
For more information, please contact me directly at 978-825-8262 or Sidney.Wong@verisk.com.
 These potential reductions are based on the Center for Medicare and Medicaid Services’ (CMS) policy to price the lowest average wholesale price (AWP) from Redbook when reviewing a Workers’ Compensation Medicare Set-Aside (WCMSA); and while the lowest AWP price applies to WCMSAs, the retail price may be priced higher in the administration of a claim.