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Naltrexone for extended-release (Vivitrol®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Vivitrol does not require prior authorization for use.

Vivitrol is generally covered and does not require prior authorization for use.

Naltrexone for extended-release injectable suspension (Vivitrol) is an opioid antagonist. It is indicated for the:

  •  prevention of relapse to opioid dependence, following opioid detoxification, and
  • treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment.

Opioid-dependent patients must be opioid-free at the time of initial Vivitrol administration. Patients should not be actively drinking at the time of initial administration. Vivitrol should be part of a comprehensive management program that includes psychosocial support.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Code

J2315 – Injection, naltrexone, depot form, 1 mg

NDC Codes

65757030001 – Vivitrol, 380 mg suspension, single use vial

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

References

  1. Alkermes. Vivitrol package insert. Waltham,MA. July 2013.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.