Dust off That Medicare Set-Aside Evaluation-Oxycodone and Lyrica Prices Have Dropped

The Center for Medicare and Medicaid Services (“CMS) recently included generic versions of Oxycodone and Lyrica in its “Red Book”.  The “Red Book” is the pricing source for prescription medications utilized by CMS when evaluating whether an appropriate amount has been set aside to cover future medical expenses in a settlement of a workers’ compensation claim.  For more about the potential cost savings from the generic form of Lyrica click here.

CMS also just announced that it was including a generic form of Oxycodone into the Red Book as well.  According to this article, for a patient on oxycodone/APAP 10mg-325mg three times daily as needed (#90 per month), with a 28 year life expectancy, the generic version would cost $23,587.20,  as opposed to $101,908.80 for the non-generic version.

I’ve posted about Medicare Set-Asides several times in the past (MEDICARE SET-ASIDE FACTS AND FICTION-PART IIMEDICARE SET-ASIDE FACTS AND FICTIONDealing With Medicare And Medicaid Liens When Settling A Workers’ Compensation Claim) so feel free to look at those posts for more detailed information.  The short version is, CMS has been very clear that the settling parties “must consider CMS’ future interests” even though the case would not be eligible for review.   Whether the parties obtain a formal MSA depends upon the circumstances of the claim, and the parties’ tolerance for risk.

If you have obtained an MSA in the past which made settling the medical portion of the claim prohibitively expensive, you may want to consider having an MSA revision performed, if the prescribing physician is willing to use the generic versions of the drugs discussed above.



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