Naltrexone (Vivitrol)


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


Six months of therapy


Last review date: December 2, 2013