Submitting a WCMSA with Lyrica to CMS for Approval? Generic Lyrica (pregabalin) Now Available in CMS’ WCMSA Portal

CMS, Rx/Pharmacy on August 2, 2019
Posted by Jean S. Goldstein, JD

You may recall our blog from last week announcing the long awaited FDA approval of generic versions of the drug, Lyrica (pregabalin).  While the FDA’s announcement sparked joy among all in the workers’ compensation industry, it was not until today that pregabalin became available for pricing and allocation in CMS’ maintained Workers’ Compensation Medicare Set-Aside (WCMSA) portal for those WCMSAs submitted for CMS approval.  The WCMSA portal relies upon a program for drug pricing that uses Truven Health Analytics’ Red Book database.  While generally Red Book database provides real time pricing of medications available, the CMS maintained WCMSA portal, is only updated monthly.  The Red book database currently has pregabalin as low $0.57 per unit.  However, this is not in line with what is reflected in the WCMSA portal, which shows pregabalin at a much more substantial cost, ranging from $7.58 to $8.42 per unit depending upon dosage.   Therefore, if submitting a WCMSA to CMS for review, it is important to be aware of this price discrepancy, and consider other cost mitigation opportunities before finalizing a WCMSA. 

Despite the availability of pregabalin in the WCMSA portal, it is important to note that it does not mean that pregabalin will automatically be allocated in a CMS approved WCMSA.   For those WCMSAs submitted to CMS for review, proof of the generic having been filled at the pharmacy or an explicit statement from the physician indicating that the generic is recommended should be reflected in the information submitted for CMS approval.  Without evidence demonstrating that the generic pregabalin is allowable and/or in use, it is likely that brand-name Lyrica will be allocated by the Workers’ Compensation Review Contractor (WCRC). 

We will continue to monitor the pricing of pregabalin and update our readers as information becomes available here on our blog.