Medicare Set-Aside Update: Generic Nexium and Its Impact on MSAs

By Kendra Phillips  |  March 25, 2015

On January 26, 2015, the FDA approved esomeprazole, the generic form of Nexium. Claims payers and the Medicare Set-Aside (MSA) industry take notice any time a widely prescribed brand-name drug becomes available as a generic. The impact of generic availability, if not immediate, can eventually prove to be dramatic.

According to the Centers for Medicare and Medicaid Services (CMS) policy, prescription drugs in an MSA should be calculated based on the average wholesale price (AWP). With Nexium, the initial AWP suggests a moderate reduction in the per-pill price of generic Nexium, regardless of dosage. As with all prescription drugs, the price is subject to change.

From an operational perspective, if the claimant is currently taking the generic form of Nexium, the Medicare Set-Aside should include the generic price. As always, it’s important to monitor prescription drugs closely. When a generic version becomes available, it can have a major impact on the amount of an MSA.

ISO Claims Partners’ team of nurses and attorneys closely monitors any issues that could potentially affect future medical allocations and Medicare Set-Asides.

Kendra Phillips is the Assistant Director of Quality Assurance at ISO Claims Partners. Kendra has been with ISO Claims Partners since 2008, and has been involved with Medicare compliance since 2005. Prior to her current position, she managed a team of attorneys and analysts, overseeing the completion of Medicare Set Asides and client communications. She is currently responsible for ensuring that all client products are of the highest quality, as well as training new employees at ISO Claims Partners. Kendra is a graduate of Boston University School of Law, and is a member of the Massachusetts and New Hampshire bars.