Limited Coverage Drugs - Paliperidone palmitate

Generic Name

paliperidone palmitate

Strength

50 mg/0.5 mL, 75 mg/0.75 mL, 100 mg/1 mL, 150 mg/1.5 mL                                              
Form injection

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  

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

Special Authority Request Form