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Network Health


Vivitrol (Naltrexone) Coverage Guidelines

Policy

This guideline applies to Tufts Health Together and Tufts Health Direct members.

We cover Vivitrol (naltrexone) with prior authorization for members who meet specific coverage criteria. Vivitrol is only available through our specialty pharmacy program as a pharmacy benefit.

Coverage criteria

We cover initial therapy with Vivitrol when a member meets the criteria for one of the following conditions:

Alcohol dependency

  • Member is currently abstaining from alcohol and opioid use, and
  • Member is currently receiving psychosocial support, and
  • Member meets one of the following criteria:
    • Member has tried and failed a trial with oral naltrexone and provider has ruled out an allergy to naltrexone, or
    • Member is a new Tufts Health Plan – Network Health member already stabilized on Vivitrol for at least the three months
     

Opioid dependency (following opioid detoxification)

  • Member is currently abstaining from opioid use, and
  • Member is currently receiving psychosocial support, and
  • Member meets one of the following criteria:
    • Member has tried and failed a trial with oral naltrexone and provider has ruled out an allergy to naltrexone, or
    • Member is a new Tufts Health Plan – Network Health member already stabilized on Vivitrol for at least the three months

We cover ongoing therapy with Vivitrol when a member meets all of the renewal criteria for one of the following conditions:

Alcohol dependency

  • Member is currently abstaining from opioid use, and
  • Member is currently abstaining from alcohol use or has shown improvement by decreasing alcohol intake or reducing use of acute care services (e.g., emergency room or detoxification visits), and
  • Member is currently receiving psychosocial support

Opioid dependency

  • Member is currently abstaining from opioid use, and
  • Member is currently receiving psychosocial support

Please note: We will approve Vivitrol treatment in one-year intervals if a member meets the criteria described for one of the conditions above.

Noncovered conditions

We do not cover Vivitrol for conditions not described in the covered conditions section.

Quantity limit

We will approve a quantity of one vial per 28 days of Vivitrol 380 mg strength.

Guidelines references

Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration (1998). "Naltrexone and alcoholism treatment." Treatment Improvement Protocol (TIP) Series 28.

Vivitrol [package insert] (2010). Cephalon.

Please note: These guidelines apply to Tufts Health Together and Tufts Health Direct plans and are incorporated by reference into Tufts Health Plan – Network Health's Provider Manual. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Tufts Health Plan – Network Health Provider Agreement. Adherence to these guidelines by a provider does not guarantee payment. We reserve the right to amend these guidelines at our discretion. 12313

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