`J2680` Fluphenazine decanoate 25 mg

Injection, fluphenazine decanoate, up to 25 mg

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 4 units per day (clinical), rationale: Prescribing Information
Outpatient hospital: max 4 units per day (clinical), rationale: Prescribing Information
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for J2680

Medicare Part B drug payment limit (ASP, October 2026)

J2680 payment limit: $6.174 per 25 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.

NDCs that bill under J2680 (CMS ASP NDC-HCPCS crosswalk, October 2026)

42023-0129-01 Fluphenazine Decanoate, Endo USA, Inc.: 5 billing units per package (1 VIAL in 1 CARTON / 5 mL in 1 VIAL)
42023-0129-89 Fluphenazine Decanoate, Endo USA, Inc.: 5 billing units per package (1 VIAL in 1 CARTON / 5 mL in 1 VIAL)
55150-0267-05 Fluphenazine Decanoate, Eugia US LLC: 5 billing units per package (1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE)
63323-0272-05 Fluphenazine Decanoate, FreseniUS Kabi USA, LLC: 5 billing units per package (1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE)
00143-9529-01 Fluphenazine Decanoate, Hikma Pharmaceuticals USA Inc.: 5 billing units per package (1 VIAL, MULTI-DOSE in 1 BOX / 5 mL in 1 VIAL, MULTI-DOSE)
67457-0359-59 Fluphenazine Decanoate, Mylan Institutional LLC: 5 billing units per package (1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE)
72205-0100-01 Fluphenazine Decanoate, Novadoz Pharmaceuticals LLC: 5 billing units per package (1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE)
25021-0838-05 Fluphenazine Decanoate, Sagent Pharmaceuticals: 5 billing units per package (1 VIAL in 1 CARTON / 5 mL in 1 VIAL)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for J2680

1 of 3 payer prior-auth lists that name J2680 require prior authorization or set conditions: UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
UnitedHealthcare Community Plan	KanCare	KS	prior auth required		Oct 1, 2026	Prior authorization requirements for Kansas Medicaid Effective October 1, 2026

Payer coverage policies that name J2680

J2680 appears in 3 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Electroconvulsive Therapy (0445)	listed, no stance	Jul 29, 2026	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range J2550-J3520)	Mar 5, 2026	payer document
Aetna	Tourette's Syndrome (0480) Tetrabenazine	covered if criteria are met	Jul 24, 2026	payer document

Recent prior-auth changes

Nov 1, 2025: PA removed, UnitedHealthcare
Apr 1, 2025: conditions changed, UnitedHealthcare
Mar 1, 2025: conditions changed, UnitedHealthcare

Medicaid fee-for-service

AZ: $5.78 (outpatient_hospital), effective Jul 1, 2026
FL: $4.00 (physician_administered_drugs), effective Jan 1, 2026
IL: $5.59 (practitioner), effective Apr 1, 2026
IN: $13.92 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2018
KS: $6.17 (default), effective Oct 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
MS: $5.59 (comprehensive), effective Jul 1, 2026
NE: $5.78 (injectables), effective Jul 1, 2026
OH: $5.59 (provider_administered_drugs), effective Jul 1, 2026
OK: $0.00 (outpatient_hospital_apc), effective Jan 1, 2026
TX: $6.20 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Sep 1, 2026
VA: $5.78 (medical), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $5.78 (professional_administered_drugs), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

J2680 Fluphenazine decanoate 25 mg