Vivitrol (Naltrexone Extended Release-Injectable) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Vivitrol (naltrexone extended release-injectable)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
□
Vivitrol (naltrexone extended
______________________
_______________________
380mg/vial
release-injectable)
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Treatment of alcohol dependence:
□
□
Yes
No Patient is being treated for alcohol dependence
□
□
Yes
No Patient has abstained from alcohol for at least 7 days in an outpatient setting prior to treatment initiation
□
□
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
□
□
Yes
No Patient is able to comply with daily dosing
□
□
Yes
No Patient is actively drinking during time of initial Vivitrol administration
□
□
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
Treatment of opioid dependence:
□
□
Yes
No Patient is using Vivitrol to prevent relapse of opioid dependence
□
□
Yes
No Patient is being treated for opioid dependence
□
□
Yes
No Patient has successfully completed an opioid detoxification program
□
□
Yes
No Patient has had an initial response and tolerates oral naltrexone (Revia)
□
□
Yes
No Patient is unable to comply with daily dosing
□
□
Yes
No Patient has been opioid-free (including buprenorphine and methadone) for at least 7 days prior to
treatment initiation
□
□
Yes
No Patient actively participates in a comprehensive rehabilitation program that includes psychosocial
support
A RESPONSE IS REQUIRED FOR EACH OF THE FOLLOWING:
□
□
Yes
No Patient is currently on opioid analgesics for pain management
□
□
Yes
No Patient is currently physiologically dependent on opioids
□
□
Yes
No Patient is currently in acute opioid withdrawal
□
□
Yes
No Patient failed the naloxone challenge test
PAGE 1 OF 2
Vivitrol NTL PAB Fax Form 4.13.11.doc
CONTINUED ON PAGE 2
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
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