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Atypical Antipsychotics – Extended Maintenance Agents Step Therapy and Quantity Limit Program Summary

Policy Number: PH-91156

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx, and Health Insurance Marketplace formularies.

POLICY REVIEW CYCLE

Effective Date

Date of Origin   

07-01-2024           

FDA LABELED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Abilify Asimtufii®

(aripiprazole)

IM injection

Treatment of schizophrenia in adults

As maintenance monotherapy treatment of bipolar I disorder in adult

13

Abilify Maintena®

(aripiprazole)

IM injection

Treatment of schizophrenia in adults 

Main monotherapy treatment of bipolar I disorder in adults

1

Aristada Initio®

(aripiprazole)

IM injection

In combination with oral aripiprazole, is indicated for the initiation of Aristada when used for the treatment of schizophrenia in adults

3

Aristada®

(aripiprazole)

IM injection

Treatment of schizophrenia in adults

2

Invega Hafyera™

(paliperidone)

IM injection

Treatment of schizophrenia in adults after they have been adequately treated with:

  • A once-a-month paliperidone palmitate extended-release injectable suspension (e.g., Invega Sustenna) for at least four months  

         OR     

  • An every-three-month paliperidone palmitate extended-release injectable suspension (e.g., Invega Trinza) for at least one three-month cycle

12

Invega Sustenna®

(paliperidone)

IM injection

Treatment of schizophrenia in adults 

Treatment of schizoaffective disorder in adults as monotherapy and as an adjunct to mood stabilizers or antidepressants

4

Invega Trinza®

(paliperidone)

IM injection

Treatment of schizophrenia in patients after they have been adequately treated with Invega Sustenna (1-month paliperidone palmitate extended-release injectable suspension) for at least four months

5

Perseris®

(risperidone)

SC injection

Treatment of schizophrenia in adults

6

Risperdal Consta®

(risperidone)

IM injection

Treatment of schizophrenia

As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder

7

Rykindo®

(risperidone ER)

IM injection

Treatment of schizophrenia in adults

As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder in adults.

15

Uzedy®

(risperidone ER)

SC injection

Treatment of schizophrenia in adults

14

Zyprexa® Relprevv™

(olanzapine)

IM injection

Treatment of schizophrenia

8

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Safety

The Atypical Antipsychotics – Extended Maintenance Agents carry a black box warning for increased mortality in elderly patients with dementia-related psychosis. The warning states that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. These agents not approved for the treatment of patients with dementia-related psychosis. In addition to the FDA black box warning, Zyprexa Relprevv carries a black box warning concerning post-injection delirium/sedation syndrome. The warning states that patients are at risk for severe sedation (including coma) and/or delirium after each injection and must be observed for at least 3 hours in a registered facility with ready access to emergency response services. Because of this risk, Zyprexa Relprevv is available only through a restricted distribution program called Zyprexa Relprevv Patient Care Program and requires, prescriber, healthcare facility, patient, and pharmacy enrollment.(1-15)

Antipsychotic drug therapy generally is reserved for patients who have severe symptoms or when associated agitation, combativeness, or violent behavior puts the patient or others in danger. Current evidence indicates that the atypical antipsychotics can provide modest improvement in behavioral manifestations; some evidence suggests that efficacy may be better for psychosis than for other manifestations. Antipsychotic efficacy appears to be similar among available agents and therefore the choice of agent should be based on adverse effect profile and other patient considerations; to minimize adverse effects, the lowest possible effective dose should be used.(1-8,12-15)

REFERENCES

Number

Reference

1

Abilify Maintena prescribing information. Otsuka America Pharmaceutical, Inc. February 2020.

2

Aristada prescribing information. Alkermes, Inc. December 2023.

3

Aristada Initio prescribing information. Alkermes, Inc. December 2023.

4

Invega Sustenna prescribing information. Janssen Pharmaceuticals, Inc. July 2022.

5

Invega Trinza prescribing information. Janssen Pharmaceuticals, Inc. August 2021.

6

Perseris prescribing information. Indivior, Inc. August 2022.

7

Risperdal Consta prescribing information. Janssen Pharmaceuticals, Inc. Februaary 2021.

8

Zyprexa Relprevv prescribing information. Eli Lilly and Company. October 2023.

9

Rabins, Peter, MD, MPH, et al. Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias. Second Edition. American Psychiatric Association. Available at:https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimers.pdf.

10

Rabins PV, Rovner BW et. al.  Guideline Watch (2014) Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias. American Psychiatric Association. Available: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimerwatch.pdf.

11

Reus, Victor, MD, et al. Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia. First Edition. May 2016. American Psychiatric Association. Available at: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890426807.

12

Invega Hafyera prescribing information. Janssen Pharmaceuticals, Inc. August 2021.

13

Abilify Asimtufii prescribing information. Otsuka Pharmaceutical Co., Ltd. August 2023.

14

Uzedy prescribing information. Teva Neuroscience, Inc. May 2023.

15

Rykindo prescribing informaiton. Shandong Luye Pharmaceutical Co, Ltd. January 2023. 

POLICY AGENT SUMMARY STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

Abilify asimtufii ; Abilify maintena

aripiprazole im er susp prefilled syringe  ; aripiprazole im for er susp prefilled syringe

300 MG ; 400 MG ; 720 MG/2.4ML ; 960 MG/3.2ML

M ; N ; O ; Y

N

Abilify maintena

aripiprazole im for extended release susp

300 MG ; 400 MG

M ; N ; O ; Y

N

Aristada ; Aristada initio

aripiprazole lauroxil im er susp prefilled syr

1064 MG/3.9ML ; 441 MG/1.6ML ; 662 MG/2.4ML ; 675 MG/2.4ML ; 882 MG/3.2ML

M ; N ; O ; Y

N

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1092 MG/3.5ML

M ; N ; O ; Y

N

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1560 MG/5ML

M ; N ; O ; Y

N

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML

117 MG/0.75ML

M ; N ; O ; Y

N

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML

156 MG/ML

M ; N ; O ; Y

N

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML

234 MG/1.5ML

M ; N ; O ; Y

N

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML

39 MG/0.25ML

M ; N ; O ; Y

N

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML

78 MG/0.5ML

M ; N ; O ; Y

N

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML

273 MG/0.88ML

M ; N ; O ; Y

N

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML

410 MG/1.32ML

M ; N ; O ; Y

N

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML

546 MG/1.75ML

M ; N ; O ; Y

N

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML

819 MG/2.63ML

M ; N ; O ; Y

N

Perseris

risperidone subcutaneous for er susp prefilled syr

120 MG ; 90 MG

M ; N ; O ; Y

N

Risperdal consta

risperidone microspheres for im extended rel susp

12.5 MG ; 25 MG ; 37.5 MG ; 50 MG

M ; N ; O ; Y

O ; Y

Rykindo

risperidone for im extended release suspension

25 MG ; 37.5 MG ; 50 MG

M ; N ; O ; Y

N

Uzedy

risperidone subcutaneous er susp pref syr

100 MG/0.28ML ; 125 MG/0.35ML ; 150 MG/0.42ML ; 200 MG/0.56ML ; 250 MG/0.7ML ; 50 MG/0.14ML ; 75 MG/0.21ML

M ; N ; O ; Y

N

Zyprexa relprevv

olanzapine pamoate for extended rel im susp

210 MG ; 300 MG ; 405 MG

M ; N ; O ; Y

N

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Abilify asimtufii

aripiprazole im er susp prefilled syringe

720 MG/2.4ML

1

Syringe

56

DAYS

Abilify asimtufii

aripiprazole im er susp prefilled syringe

960 MG/3.2ML

1

Syringe

56

DAYS

Abilify maintena

Aripiprazole IM For ER Susp Prefilled Syringe 300 MG

300 MG

1

Syringe

28

DAYS

Abilify maintena

Aripiprazole IM For ER Susp Prefilled Syringe 400 MG

400 MG

1

Syringe

28

DAYS

Abilify maintena

aripiprazole im for extended release susp

300 MG ; 400 MG

1

Vial

28

DAYS

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 1064 MG/3.9ML

1064 MG/3.9ML

1

Syringe

56

DAYS

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 441 MG/1.6ML

441 MG/1.6ML

1

Syringe

28

DAYS

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 662 MG/2.4ML

662 MG/2.4ML

1

Syringe

28

DAYS

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 882 MG/3.2ML

882 MG/3.2ML

1

Syringe

28

DAYS

Aristada initio

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 675 MG/2.4ML

675 MG/2.4ML

1

Kit

180

DAYS

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1092 MG/3.5ML

1

Syringe

180

DAYS

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1560 MG/5ML

1

Syringe

180

DAYS

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML

117 MG/0.75ML

1

Kit

28

DAYS

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML

156 MG/ML

1

Kit

28

DAYS

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML

234 MG/1.5ML

1

Kit

28

DAYS

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML

39 MG/0.25ML

1

Kit

28

DAYS

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML

78 MG/0.5ML

1

Kit

28

DAYS

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML

273 MG/0.88ML

1

Syringe

84

DAYS

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML

410 MG/1.32ML

1

Syringe

84

DAYS

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML

546 MG/1.75ML

1

Syringe

84

DAYS

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML

819 MG/2.63ML

1

Syringe

84

DAYS

Perseris

risperidone subcutaneous for er susp prefilled syr

120 MG ; 90 MG

1

Kit

28

DAYS

Risperdal consta

risperidone microspheres for im extended rel susp

12.5 MG ; 25 MG ; 37.5 MG ; 50 MG

2

Vials

28

DAYS

Rykindo

risperidone for im extended release suspension

25 MG

2

Vials

28

DAYS

Rykindo

risperidone for im extended release suspension

37.5 MG

2

Vials

28

DAYS

Rykindo

risperidone for im extended release suspension

50 MG

2

Vials

28

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

50 MG/0.14ML

1

Syringe

28

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

75 MG/0.21ML

1

Syringe

28

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

100 MG/0.28ML

1

Syringe

28

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

125 MG/0.35ML

1

Syringe

28

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

150 MG/0.42ML

1

Syringe

56

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

200 MG/0.56ML

1

Syringe

56

DAYS

Uzedy

risperidone subcutaneous er susp pref syr

250 MG/0.7ML

1

Syringe

56

DAYS

Zyprexa ; Zyprexa relprevv ; Zyprexa zydis

olanzapine for im inj  ; olanzapine orally disintegrating tab  ; olanzapine pamoate for extended rel im susp  ; olanzapine tab

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 210 MG ; 300 MG ; 405 MG ; 5 MG ; 7.5 MG

30

Unit

30

DAYS

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 210 MG (Base Eq)

210 MG

2

Vials

28

DAYS

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq)

300 MG

2

Vials

28

DAYS

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 405 MG (Base Eq)

405 MG

1

Vial

28

DAYS

CLIENT SUMMARY – STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Abilify asimtufii ; Abilify maintena

aripiprazole im er susp prefilled syringe  ; aripiprazole im for er susp prefilled syringe

300 MG ; 400 MG ; 720 MG/2.4ML ; 960 MG/3.2ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Abilify maintena

aripiprazole im for extended release susp

300 MG ; 400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada ; Aristada initio

aripiprazole lauroxil im er susp prefilled syr

1064 MG/3.9ML ; 441 MG/1.6ML ; 662 MG/2.4ML ; 675 MG/2.4ML ; 882 MG/3.2ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1560 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1092 MG/3.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML

117 MG/0.75ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML

156 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML

234 MG/1.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML

39 MG/0.25ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML

78 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML

273 MG/0.88ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML

410 MG/1.32ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML

546 MG/1.75ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML

819 MG/2.63ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Perseris

risperidone subcutaneous for er susp prefilled syr

120 MG ; 90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Risperdal consta

risperidone microspheres for im extended rel susp

12.5 MG ; 25 MG ; 37.5 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rykindo

risperidone for im extended release suspension

25 MG ; 37.5 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

100 MG/0.28ML ; 125 MG/0.35ML ; 150 MG/0.42ML ; 200 MG/0.56ML ; 250 MG/0.7ML ; 50 MG/0.14ML ; 75 MG/0.21ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa relprevv

olanzapine pamoate for extended rel im susp

210 MG ; 300 MG ; 405 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Abilify asimtufii

aripiprazole im er susp prefilled syringe

960 MG/3.2ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Abilify asimtufii

aripiprazole im er susp prefilled syringe

720 MG/2.4ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Abilify maintena

Aripiprazole IM For ER Susp Prefilled Syringe 300 MG

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Abilify maintena

Aripiprazole IM For ER Susp Prefilled Syringe 400 MG

400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Abilify maintena

aripiprazole im for extended release susp

300 MG ; 400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 1064 MG/3.9ML

1064 MG/3.9ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 441 MG/1.6ML

441 MG/1.6ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 662 MG/2.4ML

662 MG/2.4ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 882 MG/3.2ML

882 MG/3.2ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aristada initio

Aripiprazole Lauroxil IM ER Susp Prefilled Syr 675 MG/2.4ML

675 MG/2.4ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1092 MG/3.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega hafyera

Paliperidone Palmitate ER Susp Pref Syr

1560 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML

117 MG/0.75ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML

156 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML

234 MG/1.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML

39 MG/0.25ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega sustenna

Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML

78 MG/0.5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML

273 MG/0.88ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML

410 MG/1.32ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML

546 MG/1.75ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega trinza

Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML

819 MG/2.63ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Perseris

risperidone subcutaneous for er susp prefilled syr

120 MG ; 90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Risperdal consta

risperidone microspheres for im extended rel susp

12.5 MG ; 25 MG ; 37.5 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rykindo

risperidone for im extended release suspension

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rykindo

risperidone for im extended release suspension

37.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rykindo

risperidone for im extended release suspension

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

125 MG/0.35ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

150 MG/0.42ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

200 MG/0.56ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

250 MG/0.7ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

75 MG/0.21ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

100 MG/0.28ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Uzedy

risperidone subcutaneous er susp pref syr

50 MG/0.14ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa ; Zyprexa relprevv ; Zyprexa zydis

olanzapine for im inj  ; olanzapine orally disintegrating tab  ; olanzapine pamoate for extended rel im susp  ; olanzapine tab

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 210 MG ; 300 MG ; 405 MG ; 5 MG ; 7.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 210 MG (Base Eq)

210 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq)

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa relprevv

Olanzapine Pamoate For Extended Rel IM Susp 405 MG (Base Eq)

405 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

STEP THERAPY CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

TARGET AGENT(S)

PREREQUISITE AGENT(S)

Abilify Asimtufii (aripiprazole)
Abilify Maintena (aripiprazole)
Aristada (aripiprazole)
Aristada Initio (aripiprazole)

Any oral brand or generic:

Abilify
Abilify Mycite
aripiprazole ODT
aripiprazole solution
aripiprazole

Invega Hafyera (paliperidone)

Invega Sustenna
Invega Trinza

Invega Sustenna (paliperidone)

Any oral brand or generic:

Invega ER
paliperidone ER

Invega Trinza (paliperidone)

Invega Sustenna

Perseris (risperidone)
Risperdal Consta (risperidone)
Rykindo (risperidone ER)
Uzedy (risperidone ER)

Any oral brand or generic:

Risperdal
Risperdal solution
risperidone
Risperidone ODT, ​​​risperidone ODT

Zyprexa Relprevv (olanzapine)

Any oral brand or generic:

olanzapine
Zyprexa
Zyprexa Zydis

* - generic available

Target Agent(s) will be approved when ONE of the following is met:

  1. The patient has been treated with the requested agent within the past 180 days OR
  2. The prescriber states the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  3. The patient has a medication history of use in the past 365 days, intolerance, or hypersensitivity to one prerequisite agent OR
  4. The patient has an FDA labeled contraindication to ALL prerequisite agents that are not expected to occur with the requested agent

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

 

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does not have a maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication

Length of Approval: up to 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP _  Commercial _ PS _ Atypical_Antipsychotics_Extended_Maintenance_STQL _ProgSum_ 07-01-2024  _  © Copyright Prime Therapeutics LLC. May 2024 All Rights Reserved