Insight Matters
Spring, 2004

Risperdal Consta: now available in the public mental health system*
by Mark R. Munetz, M.D., Immediate Past President

There has been great interest in the availability Risperdal Consta, the first long-acting injectable second generation antipsychotic medication, in the public mental health system in Ohio. For that reason we were pleased to receive an April 27, 2004 memorandum from Drs. Mike Hogan and Dale Svendsen of the Ohio Department of Mental Health announcing that effective April 1, 2004 Risperdal Consta is available as a medical benefit. The memo notes:

For various reasons, principally the method of administration, Medicaid will cover the medication not under the pharmacy benefit, but instead as a medical benefit. Because the medication comes in a prepackaged kit with a needle and because the medication needs to be refrigerated, a patient cannot pick up this medication using a prescription. Instead the medication must be pre-purchased by the community mental health center (CMHC) from a specialty pharmacy, drug wholesaler or manufacturer. The medication will be administered in the CMHC. This is essentially the first psychotropic medication to be made available in this way.

Community mental health agencies must obtain a Medicaid provider number and bill ODJFS directly for this medication. The details of how to acquire, bill, and access this medication are contained in ODJFS Medical Assistance Letter (MAL) No. 464 which is dated April 7, 2004.

Members of OPA should applaud Directors Hogan (ODMH) and Hayes (ODJFS) for coming together and problem solving so the that public sector patients can benefit from this new pharmacological tool without a major resource drain on the already hurting public mental health system.

However, as this issue of Insight Matters goes to press here remain a number of answered questions. Thus the * in the title.

* It is not clear how long it will take for mental health centers to get the new Medicaid provider numbers and work through the mechanism to bill ODJFS directly. It is this direct billing, as I understand it, that is critical as otherwise ADMHS and Mental Health Boards would have to pay the 40% Medicaid match.

* It appears that the Medicaid reimbursement rate may be somewhat less than the acquisition cost of the medication. This added cost, though far less than the 40% match, may still discourage some agencies from using Risperdal Consta.

While it is expected that Medicare will also, eventually, reimburse for Risperdal Consta, as Medicare does for other injectable medications administered in a physician's office, details of how this will work are unclear. The ODMH memo suggests the following:

Questions related to Medicare coverage of Risperdal Consta should be directed to Palmetto GBA Medicare Part B Carrier at P.O. Box 182471 Columbus, Ohio 43218-2471 or you may call 877-567-9232.

The Risperdal Consta story provides a fascinating glimpse into our ever more complex world of clinical innovation, pharmaco-economics, cost shifting and cost offsets. OPA will keep the membership informed as developments unfold.

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