Medicare and the Opioid Epidemic

1.15.2019 Blog

As of January 1, 2019, Medicare Part D prescription drug plans began implementing a three part plan to help combat the nation’s opioid epidemic.  The plan focuses on the prevention of new cases of opioid use disorder and the treatment of opioid dependent and addicted patients through the use of nationwide utilization data.  Close partnerships with treating providers and pharmacies are essential to the success of the plan.

Four specific groups of patients are targeted by the plan: new opioid users; chronic opioid users; users at risk due to concurrent medications and those that are high risk opioid users.  Improved safety edits for pharmacy dispensed opioids, access to drug management programs and close coordination with providers form the foundation of the new plan.

While we applaud the steps being taken by the Medicare Part D plans to curtail the opioid epidemic, CMS’ current review process for Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) involving opioids unfortunately only serves to fuel the opioid epidemic.  For those unfamiliar with CMS’ current drug projection methodology, CMS projects drugs on a monthly basis for life by extrapolating data from recent pharmacy history payment records.  By recommending funding of future medical allocations that include the cost of lifetime opioids and requiring the use of the WCMSA funds to pay for the injury related Medicare covered drugs, claimants  are not subject to any of the Medicare Part D plan or any drug plan oversight.

The inherent risks associated with opioid drug projections in the WCMSA have been brought to the attention of various members of Congress and CMS’ Administrator by representatives from the National Alliance of Medicare Set-Aside Professionals (NAMSAP) over the past few years.  On December 14, 2017 CMS posted an Alert on its Coordination of Benefits & Recovery website that acknowledged the WCMSA and opioid issue.  The Alert stated “Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.”  In light of the actions taken by Medicare’s Part D prescription drug plans, it is time for CMS’ Workers’ Compensation Review Contractor to follow suit by modifying the opioid drug projection methodology used in the review of Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA).


The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.