Lyrica Now Included by CMS in WCMSAs
Lyrica (pregabalin) is an FDA approved medication for treatment of epilepsy, diabetic neuropathic pain, post-herpetic neuralgia, fibromyalgia, and other neuropathic pain. However, it is widely used off-label for treatment of chronic pain and, in some cases, anxiety disorder. Historically, the CMS Workers’ Compensation Review Contractor (WCRC) has excluded Lyrica from Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) when prescribed for pain or radiculopathy. Recently, however, the WCRC has included Lyrica in some WCMSAs, citing the acceptance in the medical community for this off-label use.
The downside of this for our clients is that Lyrica remains very expensive and inclusion of this medication in a WCMSA will drive up the cost of settlement. Our clients should consider strategies to eliminate coverage of Lyrica in their cases that are approaching settlement to avoid the need to include this in a WCMSA. These strategies may include use of the Medical Treatment Guidelines, IME Review of medical necessity, or negotiation with the claimant for consideration of other medications. Additionally, we note that the revised draft pharmacy formulary published on 10/17/18 permits use of Lyrica as a “Phase C” medication for use either upon acceptance or establishment of the claim or after 30 days from the date of injury. It is noted as a “second line” medication for injuries involving the back, CRPS, neck, or for treatment under the Non-Acute Pain Medical Treatment Guidelines. This means that the claimant must first have an unsuccessful trial of a first line medication under the Medical Treatment Guidelines before being prescribed Lyrica. For questions about how to address this and other medication issues in your WCMSAs, please contact our partner Dan Bowers.