Long Acting Atypical Anti-Psychotic Injections

• We have received some inquires from our Mental Health clinics regarding Medicaid reimbursement for the long-acting injectables, Risperdal Consta, Invega Sustenna, & Zyprexa Relprevv, Haldol Decanoate and Prolixin Decanoate.

  Currently, Medicaid reimburses up to the amount on the Medicare price list for the three excluded drugs, Risperdal Consta, Invega Sustenna & Zyprexa Relprevv. For these three atypicals, Fee for Service (FFS) Medicaid covers these products only as physician services and not as a pharmacy benefit.  The patient may not use their FFS Medicaid Benefit card and have the prescription filled at the pharmacy to bring to the physician.

  It was our understanding from the many conversations with Department of Health (DOH) that they planned to add Haldol Decanoate and Prolixin Decanoate to this method of reimbursement for FFS Medicaid patients. We have not received confirmation that this has occurred.  Neither Haldol Decanoate nor Prolixin Decanoate is included in the Medicaid Managed Care plan MH (SSI) carve out (only Risperdal Consta, Invega Sustenna, & Zyprexa Relprevv).  The injectable versions of Haldol Decanoate and Prolixin Decanoate are available through the Medicaid Managed Care plan or, for clients not enrolled in Medicaid Managed Care, as a prescription filled through the local pharmacy and reimbursed through eMedNY as a pharmacy benefit.

  The Medicare File website is updated on a regular basis.

  DOH is expected to issue a Medicaid Update in the near future.  If the reimbursement policy in the Update is different than our current understanding, you will be notified.
• Changes to the Medicaid Coverage and Billing Requirements for Risperdal Consta, Invega Sustenna and Zyprexa Relprevv.

Comments or questions about the information on this page can be directed to Financial Planning.