Limited coverage drugs – paliperidone palmitate

Last updated on January 22, 2024

Generic name

paliperidone palmitate

Strength

Invega Sustenna®50 mg/0.5 mL, 75 mg/0.75 mL, 100 mg/1 mL, 150 mg/1.5 mL

Invega Trinza®: 175 mg/0.875 mL, 263 mg/1.315 mL, 350 mg/1.75 mL, 525 mg/2.625 mL

Form

prolonged-release injectable suspension in a pre-filled syringe

Special Authority criteria

Approval period

Management of the manifestations of schizophrenia or related psychotic disorders (not dementia-related) in:

  1. patients who have tried oral paliperidone, aripiprazole or risperidone and at least one other antipsychotic agent
    AND
    whose condition continues to be inadequately controlled at maximally tolerated doses

OR

  1. patients who are currently receiving a conventional depot antipsychotic
    AND
    are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia.

OR

  1. patients with a history of non-adherence to antipsychotic medication resulting in negative outcomes such as repeated hospitalizations

Indefinite

Practitioner exemptions

  • No practitioner exemptions

Special notes

  • Criteria applicable to all plans including Plan G
  • Coverage is not available for this formulation under Plan P

Special Authority requests