Limited Coverage Drugs - Special Authority Criteria

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

Criteria Approval Period

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

1. Patients who have tried oral risperidone
PLUS
at least one other antipsychotic agent
PLUS
continue to be inadequately controlled at maximally-tolerated doses

Indefinite

 

 

 

OR

2. Patients who are currently receiving  a conventional depot antipsychotic
PLUS
experiencing significant side effects such as Extrapyramidal symptoms or Tardive dyskinesia

Indefinite
OR
3. Patients with a history of non-adherence as evidenced by outcomes such as repeated hospitalizations Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Criteria applicable for all plans including Plan G.

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