New announcement regarding Hydrocodone combination product coverage changes in Medicare Part D effective for WCMSA proposals

CMS, Medicare Set-Aside Blog, Rx/Pharmacy on November 19, 2014
Posted by Jean S. Goldstein, JD, CMSP

On November 19, CMS issued an alert regarding a CMS trend we have been seeing more frequently as related to more frequent physician visits.  The alert specifically refers to action taken by the U.S. Drug Enforcement Administration regarding rescheduling of hydrocodone combination products from C-III controlled substances to C-II controlled substances.  Based on this classification, more frequent provider visits may be necessary for Claimants to obtain prescriptions for hydrocodone combination products.

Per the CMS alert:

Usually, C-IIIs required a new prescription after five refills or after six months, whichever occurs first. C-IIs require new prescriptions at intervals no greater than 30 days; however, a practitioner may issue up to three consecutive prescriptions in one visit authorizing the patient to receive a total of up to a 90 day supply of a C-II.  For this reason, and to ensure appropriate future funding, Medicare WCMSA guidelines will change on January 1, 2015 for all new cases submitted after that date to:

At a minimum, allocate 4 healthcare provider visits per year when schedule II controlled substances (including hydrocodone combination products) are used continuously unless healthcare provider visits are more frequent per medical documentation.

As you may know, we have seen CMS frequently allocate for additional and more frequent physician visits in many cases, usually based upon the medications allocated and the frequency by which Claimants have recently been following up with their physicians.  The inclusion of quarterly, if not more frequent, physician visits is a trend we have been seeing in many cases recently reviewed.

The alert can be found here: