Pursuant to Section 22.214.171.124 of the WCMSA Reference Guide, version 2.8, prescription medication pricing is based upon the Average Wholesale Price (AWP) of the drug with generic drugs being priced at the lowest non-repacked AWP rate. In accordance with WCMSA pricing guidelines, NuQuest submitted a WCMSA utilizing the lowest AWP price for a prescribed generic medication. CMS thereafter issued an approval letter increasing the price of the medication by approximately $17,000. After a critical review of the CMS determination by the NuQuest medical team, it was found that CMS did not follow the protocol outlined in Section 126.96.36.199 of the Guide and, instead, priced the generic medication at a much higher rate. NuQuest thereafter filed a Re-Review outlining the mistake in pricing. CMS agreed with the Re-Review and issued a new approval letter including our original pricing for the medication.
This case not only illustrates the importance of understanding WCMSA guidelines, but also the need to critically review CMS determinations to make sure these guidelines are followed. Failure to do so can result in increased WCMSA costs and missed opportunities for WCMSA reductions. NuQuest will continue to advocate for clients throughout the WCMSA process to help ensure CMS protocols are followed. Should you have any questions or need further information on our MSA services, please contact NuQuest at (866) 858-7161.