Prescription drugs for Medicare beneficiaries

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DATE: May 14, 2010

FROM: Director, Financial Services Group, Office of Financial Management

SUBJECT: Medicare Secondary Payer--Workers’ Compensation--INFORMATION

TO:  Consortium Administrator for Financial Management and Fee-for-Service Operations

The purpose of this memorandum is to clarify guidance provided in the Centers for Medicare & Medicaid Services’ (CMS’) April 3, 2009 and July 1, 2009 procedure memoranda regarding prescription drugs administered to Medicare beneficiaries for off-label and/or unlabeled outpatient uses and whether these drugs are considered covered by Medicare Part D and, therefore, appropriately included in a Medicare Workers’ Compensation Set-aside Agreement (WCMSA) proposal. Also, this memorandum changes the Rated Age (RA) language to be included in WCMSAs, as detailed in the August 25, 2008 procedure memorandum.

Our first priority is the health and well being of beneficiaries. This includes ensuring that beneficiaries receive the most value from the services paid for by Medicare. To this end CMS is providing more guidance about covered drugs and rated age.  I wanted to make you and your staff aware of these changes.

Definition of Covered Part D Drugs:

A “covered Part D drug” is “a drug that may be dispensed only upon a prescription and that is described in subparagraph (A)(i), (A)(ii), or (A)(iii) . . .” of 42 U.S.C. section 1396r-8(k)(2). 42

CMS performs a re-pricing of the WCMSA, beneficiaries and claimants may not use funds from their WCMSA to pay for non-covered Part D drugs. Doing so constitutes an inappropriate expenditure of WCMSA funds.

The previous Rated Age (RA) statement from the submitter that all rated ages obtained on the claimant have been included is now rescinded.

“Our organization certifies that all rated ages obtained on the claimant, at any time during that individual claimant’s lifetime, have been included as part of this submission to the Centers for Medicare & Medicaid Services.”


Source: The Centers for Medicare and Medicaid Services

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