VIVITROL (naltrexone)

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