Limited Coverage Drugs - paliperidone palmitate

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

  • Coverage is not available for this formulation under Plan P

Special Authority Request Form