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INDEX:

Effective Date: 11/01/2007

Title: Vivitrol

Revision Date: 12/01/2020

Document: BI213:00

CPT Code(s): J2315

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) Vivitrol (naltrexone injection) is an Injectable medication which helps people who are addicted to alcohol to remain abstinent and is also used to prevent relapse following opioid detoxification in people who are opioid dependent.

2) Vivitrol is covered with pre-authorization.

Medical Statement

1) Vivitrol (naltrexone injection) is covered when it is a part of an integrated outpatient abstinence program that includes a formal abstinence support program (such as AA) and an interview monthly with the administering psychiatrist to make a determination about the patient’s persistence in treatment and eligibility to continue on treatment.

2) Vivitrol requires pre-authorization as part of the treatment plan submitted for the patient.

3) Pre-authorization for alcohol dependence is based on:

a) Recent hospitalization related to alcoholism (within 6 months); AND

b) Agreement on the part of the patient to follow a regimen of treatment; AND

c) A plan of treatment that includes at least monthly visits with the treating physician.

d) Participation in an abstinence support program

4) Pre-authorization for opioid dependence is based on:

a) Documented history of opioid dependence with confirmed abstinence at treatment initiation: AND

b) Agreement on the part of the patient to follow a regiment of treatment; AND

c) A plan of treatment that includes at least monthly visits with the treating physician; AND

5) Participation in an abstinence support program. The initial prior authorization will be for six months (six injections). Further treatment will require another preauthorization, which will be based on the fact that the patient is:

a) Receiving documented clinical benefit from the Vivitrol; AND

b) Is compliant with and making progress in the abstinence support program.

Codes Used In This BI:

J2315

Naltrexone, depot form

Background

1) Vivitrol is a long acting Injectable form of naltrexone.

2) Naltrexone taken by mouth has been shown to be effective in assisting patients with alcoholism to remain abstinent. It works as well as or better than previously available medications such as Antabuse or Campral. It is also effective in preventing relapse following opioid detoxification in people who are opioid dependent.

3) Vivitrol appears to be more effective than oral naltrexone, in part because of the short duration of action of oral naltrexone, and the possibility that the patient can have a short time from decision about taking the medication to taking alcohol. The month-long duration of Vivitrol, in combination with a program of psychotherapy, results in fewer non-abstinent days and less disruption of functioning from those days.

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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