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
|