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Medicare set-aside update: Generic Nexium and its impact on MSAs

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.

Per-pill pricing of generic Nexium

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.

Joshua Coleman 623117 Unsplash

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.

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


Kendra Phillips

Kendra Phillips is director of quality assurance at ISO Claims Partners, a Verisk business. You can contact Kendra at kphillips@verisk.com.


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