More topics

Limited coverage criteria – paliperidone palmitate

Last updated on March 20, 2025

 

Return to Special Authority drug list

Generic name

paliperidone palmitate

  

Brand name

Strength

Form

Invega Sustenna®

 50 mg/0.5 mL, 75 mg/0.75 mL, 100 mg/1 mL, 150 mg/1.5 mL prolonged-release injectable suspension in a pre-filled syringe
Invega Trinza® 75 mg/0.875 mL, 263 mg/1.315 mL, 350 mg/1.75 mL, 525 mg/2.625 mL 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:

  • 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

  • patients who are currently receiving a conventional depot antipsychotic

    AND
     
  • are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia

OR

  • 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 request form(s)