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The Optum clinical team can help you move your claims to settlement

by | May 15, 2019

August 20, 2018 
by Evelio Prieto, PharmD., RPh., CPh.

It is common for medications to comprise a large proportion of a Workers’ Compensation Medicare Set-Aside (WCMSA) allocation. Often times the cost of prescription medications can drive up claim costs and prohibit settlement. Clinical interventions that both improve the injured worker’s medication regimen and aid in decreasing costs are tools that Optum provides to assist our clients. Part of our approach is monitoring RED BOOK® Average Wholesale Price (AWP) for the most common medications present in (WCMSA) arrangements. Through this process, we identify price adjustments which positively or negatively affect the WCMSA.

In the month of July we saw price increases for Vesicare® tablets (used in the treatment of bladder conditions) and Gralise® tablets (gabapentin extended release for neuropathic pain). There was a price decrease for hydromorphone extended release tablets (long-acting opioid for chronic pain).

The products in the table below have a change in AWP, confirmed in the Centers for Medicare and Medicaid Services (CMS) WCMSA portal.

Product name

NDC code

Dosage form

Strength

AWP unit price
reduction/increase

Hydromorphone

13811070110

ER Tablets

8 mg

-$5.85

Hydromorphone

13811070210

ER Tablets

12 mg

-$7.20

Hydromorphone

13811070310

ER Tablets

16 mg

-$9.60

Hydromorphone

13811070410

ER Tablets

32 mg

-$19.20

Gralise

13913000419

Tablets

300 mg

$0.92

Gralise

13913000519

Tablets

600 mg

$0.92

Vesicare

51248015052

Tablets

5 mg

$0.82

Vesicare

51248015103

Tablets

10 mg

$0.82


Please note that RED BOOK AWP is subject to change and this pricing is subject to an increase or decrease in the future.

CMS uses the lowest AWP when reviewing a WCMSA. If you have a WCMSA with hydromorphone ER tablets you will immediately benefit from a reduction in the cost of this medication. In some cases, this may make settlement a viable option.

Optum will proactively contact clients when we have previously completed a WCMSA where these medications are prescribed. It is our recommendation that carriers, TPA’s and claim handlers review cases to determine if price changes positively impact settlement options.

Optum has clinical intervention products available, which may help mitigate costs and improve patient outcomes through more suitable clinical alternatives and cost effective therapeutic equivalents. We will continue to inform the industry of AWP pricing and other changes that may affect WCMSA arrangements.


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