Affordability
INVEGA SUSTENNA® patients with Medicaid and Medicare Part D LIS may pay as low as $0 per month1,2†‡§||¶#**
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Access and affordability for INVEGA SUSTENNA®, INVEGA TRINZA®, and INVEGA HAFYERA®
INVEGA SUSTENNA® is widely covered,* and government-insured patients may pay as low as $0 per month1,2†‡
Coverage vs orals
INVEGA SUSTENNA® has comparable coverage to commonly prescribed oral antipsychotics across Medicaid and Medicare payers#**††
Coverage vs LAIs
INVEGA SUSTENNA® has superior coverage compared to other LAIs approved in the last 6 years across Medicaid and Medicare payers#**‡‡
INVEGA SUSTENNA® is widely covered,* and government-insured patients may pay as low as $0 per month1,2†‡
Affordability
INVEGA SUSTENNA® patients with Medicaid and Medicare Part D LIS may pay as low as $0 per month1,2†‡§||¶#**
Coverage vs orals
INVEGA SUSTENNA® has comparable coverage to commonly prescribed oral antipsychotics across Medicaid and Medicare payers#**††
Coverage vs LAIs
INVEGA SUSTENNA® has superior coverage compared to other LAIs approved in the last 6 years across Medicaid and Medicare payers#**‡‡
This information is not a promise of coverage or payment. It is not intended to give reimbursement advice or increase reimbursement by any payer. Legal requirements and plan information can be updated frequently. Contact the plan for more information about current coverage, reimbursement policies, restrictions, or requirements that may apply.
Managed Markets Insight and Technology, LLC™, a trademark of MMIT, as of December 2024. Collected as of December 2024 and may change.
LAI=long-acting injectable; LIS=low-income subsidy.
*Widely covered is defined as >65% number of covered lives.
†The Medicaid out-of-pocket cost range for generic oral antipsychotics in 2019 was $0.00–$343.06 and the range for INVEGA SUSTENNA® was $0.00–$348.41. 95% of patients on generic oral antipsychotics paid $3.13 or less, and 95% of patients on INVEGA SUSTENNA® paid $3.36 or less.3
‡The Medicare Part D LIS out-of-pocket cost range for generic oral antipsychotics in 2019 was $0.00-$40.80 and the range for all second-generation long-acting injectables (eg, INVEGA SUSTENNA®, was $0.00-$34.00). Medicare Part D LIS patients who paid $0 were institutionalized. Noninstitutionalized patients paid as low as $15.20 per month.2
§As demonstrated in 2 separate studies determining mean Medicaid out-of-pocket cost or median Medicare out-of-pocket cost. Medicaid benefit may vary by state. The 2 starting doses of INVEGA SUSTENNA® have been factored into the mean and median monthly patient out-of-pocket cost calculations.
||All dual-eligible Medicare Part D beneficiaries (ie, those with Medicare and Medicaid coverage) also have LIS status. However, not all full LIS patients are dual-eligible.
¶Inclusive of Medicare Part D full LIS in the pre-initial coverage limit (ICL) and ICL phases.
#See full eligibility requirements for the LIS for Medicare Prescription Drug Coverage: https://www.cms.gov/medicare/eligibility-and-enrollment/lowincsubmedicareprescov/eligibilityforlowincomesubsidy
**Above 150% of the Federal Poverty Level, patients may pay up to 20% of the amount the Medicaid agency pays. Medicaid Fee-For-Service is a state-specific program. Coverage for INVEGA SUSTENNA® may depend on the indication as well as other factors. As this information varies by state, it is important to contact the state agency directly or consult its website to obtain product-specific coverage and other information.
††Comparable coverage is defined as the absolute difference in lives covered being +/-5% across all government payers.
‡‡Superior coverage is defined as the difference in lives covered being greater than 10% across all government payers.
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Affordability may improve when patients transition to LAI formulations with longer dosing intervals3*
For adults with schizophrenia and Medicaid or Medicare Part D LIS coverage
INVEGA TRINZA® may be just as affordable as generic oral options, with less than a $1 difference in monthly out-of-pocket cost1,2†‡§||
Medicaid
Mean out-of-pocket cost per month in 2019: $0.61 (SD $2.43) for oral antipsychotics vs $0.39 (SD $1.15) for INVEGA TRINZA®1||¶
Medicare
Median out-of-pocket cost per month in 2019:$1.20 (IQR $0.00-$1.25) for oral antipsychotics vs $1.27 (IQR $1.27-$2.83) for INVEGA TRINZA®2,3§#
Affordability may improve when patients transition to LAI formulations with longer dosing intervals3*
For adults with schizophrenia and Medicaid or Medicare Part D LIS coverage
INVEGA TRINZA® may be just as affordable as generic oral options, with less than a $1 difference in monthly out-of-pocket cost1,2†‡§||
Medicaid
Mean out-of-pocket cost per month in 2019: $0.61 (SD $2.43) for oral antipsychotics vs $0.39 (SD $1.15) for INVEGA TRINZA®1||¶
Medicare
Median out-of-pocket cost per month in 2019: $1.20 (IQR $0.00-$1.25) for oral antipsychotics vs $1.27 (IQR $1.27-$2.83) for INVEGA TRINZA®2,3§#
This calculation is based on data from 2019.
This information is not a promise of coverage or payment. It is not intended to give reimbursement advice or increase reimbursement by any payer. Legal requirements and plan information can be updated frequently. Contact the plan for more information about current coverage, reimbursement policies, restrictions, or requirements that may apply.
LAI=long-acting injectable; LIS=low-income subsidy.
*This analysis was specific to government payers only.3
†All dual-eligible Medicare Part D beneficiaries (ie, those with Medicare and Medicaid coverage) also have LIS status. However, not all full LIS patients are dual-eligible.
‡Inclusive of Medicare Part D full LIS in the pre-initial coverage limit (ICL) and ICL phases.
§See full eligibility requirements for the LIS for Medicare Prescription Drug Coverage: https://www.cms.gov/medicare/eligibility-and-enrollment/lowincsubmedicareprescov/eligibilityforlowincomesubsidy
||Above 150% of the Federal Poverty Level, patients may pay up to 20% of the amount the Medicaid agency pays. Medicaid Fee-For-Service is a state-specific program. Coverage for INVEGA TRINZA® may depend on the indication as well as other factors. As this information varies by state, it is important to contact the state agency directly or consult its website to obtain product-specific coverage and other information.
¶The Medicaid out-of-pocket cost range for generic oral antipsychotics was $0.00 (min) – $343.06 (max). The Medicaid out-of-pocket cost range for INVEGA TRINZA® was $0.00 – $31.32. 95% of patients on generic oral antipsychotics paid $3.13 or less, and 95% of patients on INVEGA TRINZA® paid $1.12 or less.3
#The maximum that LIS beneficiaries paid in 2019 was $3.40 for generic drugs, and $8.50 for brand-name drugs, such as INVEGA TRINZA®. The maximum co-pay for generic oral antipsychotics was $3.40, and $8.50 for INVEGA TRINZA®.2
Affordability may improve when patients transition to LAI formulations with longer dosing intervals3*
Medicare full-benefit, dual-eligible LIS and Medicaid patients pay no more than $12.15 for INVEGA HAFYERA®4†‡§||
Affordability may improve when patients transition to LAI formulations with longer dosing intervals3*
Medicare
Medicare full-benefit, dual-eligible LIS and Medicaid patients pay no more than $12.15 for INVEGA HAFYERA®4†‡§||
This information is not a promise of coverage or payment. It is not intended to give reimbursement advice or increase reimbursement by any payer. Legal requirements and plan information can be updated frequently. Contact the plan for more information about current coverage, reimbursement policies, restrictions, or requirements that may apply.
LAI=long-acting injectable; LIS=low-income subsidy.
*This analysis was specific to government payers only.3
†All dual-eligible Medicare Part D beneficiaries (ie, those with Medicare and Medicaid coverage) also have LIS status. However, not all full LIS patients are dual-eligible.
‡Inclusive of Medicare Part D full LIS in the pre-initial coverage limit (ICL) and ICL phases.
§See full eligibility requirements for the LIS for Medicare Prescription Drug Coverage: https://www.cms.gov/medicare/eligibility-and-enrollment/lowincsubmedicareprescov/eligibilityforlowincomesubsidy
||Above 150% of the Federal Poverty Level, patients may pay up to 20% of the amount the Medicaid agency pays. Medicaid Fee-for-Service is a state-specific program. Coverage for INVEGA HAFYERA® may depend on the indication as well as other factors. As this information varies by state, it is important to contact the state agency directly or consult its website to obtain product-specific coverage and other information.
References: 1. Lin D, Pilon D, Benson C, et al. PMH7: Assessment of patient out-of-pocket costs for antipsychotic treatments among Medicaid beneficiaries with schizophrenia. Presented at: ISPOR 2021; May 17-20, 2021; Virtual. 2. Li P, Benson C, Zhi Geng Z, et al. Out-of-pocket costs for long-acting injectable and oral antipsychotics among full Low-Income Subsidy (LIS) Medicare beneficiaries with schizophrenia. Presented at: Psych Congress Elevate. June 3-5, 2022; Las Vegas, NV. 3. Data on file. Janssen Pharmaceuticals, Inc. 4. Announcement of Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. Centers for Medicare & Medicaid Services. April 1, 2024. Accessed December 19, 2024. https://www.cms.gov/files/document/2025-announcement.pdf