Allocation and pricing of medications within the Workers Compensation Medicare Set-Aside Arrangement (WCMSA) Part D is done so in accordance with the WCMSA Reference Guide as published by Center for Medicare and Medicaid Services (CMS). As a result, WCMSA medications are priced using the lowest average wholesale price (AWP) by the recognized proprietary source: Truven Health Analytics’ Red Book database. Further, generic medications are priced at the lowest non-repackaged AWP.
AWP is considered the “sticker price” and rarely what is actually paid; it is used as a benchmark in drug pricing, and it is an ever-changing number!
ExamWorks Clinical Solutions continually monitors Red Book for real-time changes to AWP for medications used to treat the injured worker. It is noted that in April 2018, gabapentin, a first line agent for neuropathic pain, had a significant reduction in pricing; $2.28 per 600mg tablet to $0.27 per tablet which positively impacts Part D in the WCMSA. Gabapentin formulations now have several outliers: 300mg capsule $0.03, 400mg capsule $0.15 and 800mg tablet $0.34.
ExamWorks Clinical Solutions best practices in providing the most accurate and defensible MSA is to utilize technology and compendia databases which are recognized and supported by the CMS to support inclusion or exclusion of a drug under the Part D benefit.
ExamWorks Clinical Solutions continues to monitor changes in medication pricing as well as availability of generic equivalents within the marketplace. For questions about medications, please contact Dr. Nahla Rizkallah, PharmD at 678-256-5086 or firstname.lastname@example.org