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Risperdal (risperidone) — Blue Cross Blue Shield of Texas

stage four advanced metastatic cancer

Preferred products

  • Any generic atypical antipsychotic
  • generic fluoxetine
  • Clozapine ODT
  • Clozaril
  • Fanapt
  • Geodon
  • Invega
  • Latuda
  • Lybalvi
  • Risperdal
  • Risperidone ODT/risperidone ODT
  • Saphris
  • Secuado
  • Seroquel

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. The prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • 2. The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes are required] AND
  • B. The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration OR
  • 2. The patient has been treated with the requested agent within the past 180 days OR
  • 3. The prescriber states the patient has been treated with the requested agent AND the patient is currently stable on the requested agent [chart notes are required] OR
  • 4. The patient has tried and had an inadequate response to ONE prerequisite agent [chart notes are required] OR
  • 5. ONE prerequisite agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] OR
  • 6. The patient has an intolerance or hypersensitivity to ONE prerequisite agent [chart notes are required] OR
  • 7. The patient has an FDA labeled contraindication to ALL prerequisite agent(s) [chart notes are required] OR
  • 8. ONE prerequisite agent is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm [chart notes are required] OR
  • 9. ONE prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes are required] OR
  • 10. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as ONE prerequisite agent and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required]

Reauthorization criteria

  • Same as initial criteria; for dementia-related psychosis renewals approved for 6 months; for other indications 12 months if criteria continue to be met.

Approval duration

BCBSIL 12 months; Dementia-related psychosis initial 3 months and renewal 6 months; all others 12 months