VIVITROL (naltrexone)
OFFICE ADMINISTRATION
Indications for Prior Authorization:
- Treatment of alcohol dependence
- Patient must be enrolled in a comprehensive psychosocial treatment program
- Patient does not have elevated LFT’s, acute hepatitis or liver failure
- Patient is opioid free for a minimum of seven-10 days prior to treatment
- Patient is currently abstinent from alcohol AND one of the following
- documented intrinsic swallowing mechanism defect, OR
- patient has tried and failed or is intolerant to both oral naltrexone and acamprosate (Campral)
- Approvable for the prevention of relapse to opioid dependence, following opioid detoxification
This Medication is Not Approvable for the following condition(s):
- Any indication not listed above
Dosing:
- The recommend dose of Vivitrol (naltrexone IM) is 380 mg every four weeks or once a month
Approval:
Six months of therapy
Last review date: December 2, 2013