Ask Annie: Converting Lyrica to Pregabalin in a Medicare Set-Aside

This week we are starting a new feature to highlight practical ways to resolve critical Medicare Secondary Payer compliance questions. Annie Davidson (and occasionally other ExamWorks experts) will answer common and topical MSP compliance questions. Annie’s aim is to simplify complex issues that are encountered every day. We hope that you enjoy the new feature. If you have a question that needs answering, feel free to Ask Annie by emailing her at Annie.Davidson@examworkscompliance.com.

This week’s Ask Annie question is: Annie, I have a claimant who is prescribed Lyrica. Now that pregabalin is available as a generic substitute, what do I need to do to ensure that my MSA is approved with pregabalin?

Answer:  If you want to ensure your Medicare Set-Aside Arrangement (“MSA”) is approved with pregabalin, it is important to make sure the claimant has switched to this generic drug and it is reflected in the medical and pharmacy records submitted for review. The records should clearly reflect the generic is not only being prescribed, but is also being filled and utilized by the claimant. The claimant and his or her counsel should understand this as well since a letter from the claimant to Medicare requesting brand-name Lyrica will thwart all efforts to include the generic pregabalin despite what the records may indicate.

Like our questioner here, you may have read in August that we saw a significant drop in the price of Lyrica due to the availability of pregabalin as a generic substitute. Here is an update of the further drop in September:

Given the availability of pregabalin, it is entirely understandable parties are looking to take advantage of the significant price drop.

Medicare’s review contractor reviews the facts of the case and the care, items, and services the claimant has received in the most recent two years to determine what amount of money the claimant should set-aside for future care related to the claimed injury.  The WCMSA Reference Guide helps all parties determine what to include, when to include it, and how to price it, including Part D Medicare plan prescription drugs. Section 9.4.6.1 of the Reference Guide indicates the review contractor prices for generic drugs unless one of the following applies, in which case the contractor uses brand-name:

• A brand-name drug is in the proposal and there is an indication that the claimant is actually taking the brand-name drug.
• A generic is in the proposal, but no generic exists.
• A generic is in the proposal, but all the evidence indicates that the claimant is taking the brand-name drug.
• The claimant or claimant’s attorney insists on a brand-name drug in writing.

No drugs are indicated in the submitted proposal, but the condition requires certain drugs, or the medical records indicate certain drugs. In this case, the WCRC will default to pricing for brand-name medications.

Of course, ExamWorks can work closely with you and your PBM to ensure that the claimant is actually switched to the generic and that the pharmacy and medical records accurately reflect this change.  Should your case be submitted to CMS, our Pharmacy and Resolutions Team will make sure the transition is adequately documented in order to put the best foot forward with CMS. 

If you have a question or an idea for a future Ask Annie column, please email Annie at annie.davidson@examworkscompliance.com or call her at 651-262-9618.