CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage and prior authorization criteria for risperidone long-acting injectable (Risperdal Consta)

Coverage and prior authorization criteria for risperidone long-acting injectable (Risperdal Consta) for members under the payer's Medicaid scope, specifying approved indications and requirements for authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRisperidone long-acting injectable (Risperdal Consta) coverage and prior authorization

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective Date6/2017

Next Review DateN/A

Key ActionObtain prior authorization and document tolerability with oral risperidone before requesting the long-acting injectable for schizophrenia or Bipolar I maintenance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsmax auth duration

Schizophrenia; Bipolar Icovered indications

Oral tolerabilitypre-auth requirement

Medicaidpayer scope

2/2025last review

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Coverage Criteria for Risperidone Long-Acting Injection

Initial authorization criteria

Authorization may be granted for 12 months when ALL of the following are met:

Authorization requirements: A. Tolerability with oral risperidone has been established; B. The requested drug is being prescribed for one of the following: 1) Treatment of schizophrenia; 2) As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder

Authorization duration: 12 months

Requests for use of risperidone long-acting injectable for any indication other than treatment of schizophrenia or maintenance treatment of Bipolar I Disorder (monotherapy or adjunctive to lithium/valproate) are considered experimental/investigational and are not a covered benefit.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. An authorization may be granted for up to 12 months when both criteria A and B are met.

Authorization duration: up to 12 months when criteria met

Documentation Required

Oral Risperidone Tolerability Requirement

Documentation must show that the member has tolerated oral risperidone prior to initiation of the long-acting injectable formulation.

Must document prior trial and tolerability with oral risperidone (e.g., dosing, adverse effects, clinical response)

Documentation Required

Required Clinical Documentation

Clinical documentation must support both the oral risperidone tolerability and the indication for use. Include relevant medical records, prior medication history, and rationale for LAI therapy.

Indication must be either: 1) treatment of schizophrenia; or 2) maintenance treatment of Bipolar I Disorder (monotherapy or adjunctive to lithium or valproate).
Include prior medication records demonstrating tolerability to oral risperidone (dates, dose, adverse reactions)
Provide clinical rationale for switching to or initiating long-acting injectable risperidone

Denial Risk

Non‑Covered Indications

Requests for indications other than schizophrenia or maintenance treatment of Bipolar I Disorder are not covered.

All other indications considered experimental/investigational and not covered

Background

Risperdal Consta (long‑acting injectable risperidone) is indicated for the treatment of schizophrenia and for the maintenance treatment of Bipolar I Disorder, either as monotherapy or as adjunctive therapy to lithium or valproate.

Definitions and Covered Indications

Covered indication

DefinitionCovered indications are FDA-approved indications and compendial uses for which all approval criteria are met and the member has no exclusions to the prescribed therapy.

Included indicationsSchizophrenia; Risperdal Consta is indicated for the treatment of schizophrenia.

Included indicationsBipolar I Disorder (maintenance): indicated as monotherapy or as adjunctive therapy to lithium or valproate for maintenance treatment.

ExclusionsAll other indications not specified (i.e., indications other than schizophrenia or Bipolar I maintenance) are considered experimental/investigational and are not a covered benefit.

Long-Acting Injectable Risperidone (Risperdal Consta)

Long-acting injectable risperidone (Risperdal Consta)

Indications: Schizophrenia OR maintenance treatment of Bipolar I Disorder (monotherapy or adjunct to lithium/valproate)

Must also meet tolerability requirement (oral risperidone) as described in initial authorization criteria