Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
paliperidone palmitate
50 mg/0.5 mL, 75 mg/0.75 mL, 100 mg/1 mL, 150 mg/1.5 mL injection

Criteria Approval Period

Management of the manifestations of schizophrenia or related psychotic disorders in:

  1. Patients who have tried oral paliperidone or risperidone

    PLUS

    at least one other antipsychotic agent

    PLUS

    continue to be inadequately controlled at maximally-tolerated dose

OR

  1. Patients who are currently receiving a conventional depot antipsychotic

    PLUS

    experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia

OR

  1. Patients with a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations
 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Criteria applicable for all plans, including Plan G
  • Patients who meet criteria for paliperidone palmitate automatically receive coverage of risperidone microspheres

Special Authority Request Forms

Online Forms (PDF)
Click on the link to complete a special authority request form.