| Anthem Blue Cross (HMO, PPO, EPO) |
| Vivitrol (naltrexone microspheres) |
| Drugs for Addiction : Drugs for Alcohol Addiction |
- Quantity Limit: 1 vial per 28 day(s).
- Substance Abuse: Alcohol Dependence:
Duration: 6 Month(s)
Medical Test Required: No
Reauthorization Required: No
Negative Test for Opioids Required: No
Rehabilitation Program Required: No
Policy Specifies Induction or Initiation of Therapy: No
Documented Diagnosis: No
Substance Abuse: Opioid Dependence:
Duration: 6 Month(s)
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Negative Test for Opioids: Yes
Rehabilitation Program Required: Yes
Policy Specifies Induction or Initiation of Therapy: No
Documented Diagnosis: Yes
Induction Period Specified: No
- Prior Authorization: PA Applies
- Available only through Specialty Pharmacy;
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