Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
risperidone microspheres 12.5mg/2mL, 25mg/2mL, 37.5 mg/2mL, 50 mg/2mL injection

Criteria Approval Period

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

  1. Patients who have tried oral risperidone or paliperidone

    2. PLUS

    at least one other antipsychotic agent

    PLUS

    continue to be inadequately controlled at maximally-tolerated doses

OR

  1. Patients who are currently receiving a conventional depot antipsychotic

    2. 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 risperidone microspheres automatically receive coverage of paliperidone palmitate

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