Naltrexone (Vivitrol)

Office administered

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.


The recommend dose of Vivitrol (naltrexone IM) is 380 mg every four weeks or once a month

Duration of Therapy

Approve for six months of therapy.

Western Health Advantage Pharmacy and Therapeutics Committee

Approved: May 2013 Reviewed: December 2013