How Do Medicare Set-Asides Handle PRN or “As Needed” Medications?

CMS has issued specific guidelines regarding how the costs of PRN or “as needed” medications should be calculated for Medicare Set-Asides (MSAs). PRN or “as needed” medications are medications that are prescribed to be taken when symptoms warrant, rather than a medication with a normal scheduled dosage such as two tablets before bedtime. PRN medications are often pain medications. In fact, some doctors will only prescribe pain medications as PRN. The reasoning is that the patient should only take the medication when absolutely necessary. The doctor doesn’t want the patient to take the medication on a schedule like they would a high blood pressure medication. Rather, the patient should assess their current pain level and only take the medication if necessary. Read on and contact our team to learn more.

This process may seem like simple common sense. However, complications arise when valuing the MSA. Some MSA Vendors will see a medication is prescribed PRN and automatically default to a preset number of pills per year. 150 pills are a common example. This default number does not take into account how many pills the injured worker has historically taken for pain control. Rather the preset default number is based on trying to lower the cost of the MSA.    In addition, the Insurance Company and its Vendor may have a utilization review physician or pharmacy write a report outlining a weaning program to reduce the frequency and dosage of medication.

So how does Medicare feel about valuing the future cost of PRN medications?

For Medicare’s guidance on PRN medications, we should turn to the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide.  The Current Version 3.7 was issued on June 6, 2022.   The Reference Guide is compilation of CMS’s internal operating rules for the Workers Compensation Review Contractor (WCRC) to process and value MSAs.

Section Pharmacy Guidelines and Conditions discuss PRN medications in detail. 

The WCRC considers any medication with variable usage in a two month or greater period within the last year a PRN medication. It is important to note that the Guide references the usage and not the amount prescribed. The exception is if the Claimant has been non-compliant with treatment.   Then the WCRC must consider the amount prescribed rather than the actual usage.

The next step is for the WCRC to use the historical usage to determine a reasonable future usage.  Some additional factors the WCRC may consider are whether:

  • the Claimant’s condition is improving or getting worse
  • the drug usage has increased or decreased in the past three to six months,
  • the Claimant has started on any other medication that may reduce the as-needed drug usage,
  • the Claimant received a surgery or other medical procedure that has changed their medical situation so as to reduce their drug usage, or
  • the Claimant’s condition has declined that they may need more drug usage in the future.

Through this analysis is it important to remember that the Reference Guide specifically states that “the WCRC mainly bases as-needed drug usage on past drug history, and makes judgments on what may be reasonably probable in the future based on the Claimant’s current condition.”

Nowhere in this analysis does it state PRN medications may be calculated at 150 pill per year, or any other default number. Moreover, a weaning program will only be accepted by Medicare, if there is documentation in the medical records that the program has been initiated and the Claimant has successfully reduced usage. If you are presented with a MSA proposal that uses an arbitrary preset number of pills or offers a weaning program that has not been initiated, you should immediately question its validity, as it is most likely not a fair projection of future medication costs.

So how do you combat an MSA proposal that uses a default number of PRN medications or a proposed weaning program?

Your best approach is an independent review of the MSA Proposal by a Vendor with the Injured Workers’ interests at heart. MSA Meds will review the Insurance Company’s MSA Proposal and compare it to the actual medication history and provide a fair and realistic projection of PRN medication based on the Claimant’s actual usage.

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Contact MSA Meds today to learn more about how we can help ensure that Injured Workers receive the medical treatment they need after settlement.