Vivitrol Statement Of Medical Necessity

®

VIVITROL

Phone: (800) 906-7798

FAX: (877) 381-3806

STATEMENT OF MEDICAL NECESSITY

PATIENT DEMOGRAPHICS

PRESCRIBER INFORMATION

SEX: M F

PATIENT NAME: ______________________________________________

PRESCRIBER NAME: _____________________________________________________

ALLERGIES:________________________________ Weight: ______lbs/kg Height:______

MD LICENSE #: ______________________ MD NPI#: ___________________________

DATE OF BIRTH: _______________ SOCIAL SECURITY #: ________________________

CLINIC NAME: _______________________________SPECIALTY:___________________

A

CONTACT NAME: ________________________________________________________

DDRESS: _________________________________________________ APT#_________

ADDRESS: _________________________________ SUITE #: ____________________

CITY: ______________________________________ STATE: ______ ZIP: __________

CITY: _________________________________ STATE: ________ ZIP: ____________

HOME PHONE: ________________________ Cell PHONE: ________________________

PHONE: _____________________________ FAX: ______________________________

ALTERNATE CONTACT NAME: ________________________Phone: _________________

INSURANCE INFORMATION

Please include copies of the patient’s insurance/drug benefit cards (front and back)

INSURANCE INFORMATION

Primary Insurance: _______________________________________

Relationship:

Self

Spouse

Child

Policy #: __________________________________

Pharmacy Benefit Plan (PBM) Name: _________________________________________ PBM Phone #: _____________________________

Policy #__________________________________________________

RX Group: ___________________ RX BIN #: ____________________ RX PCN #: _______________

INJECTION SITE INFORMATION (If Different then Prescriber Information Above)

CLINIC NAME: __________________________________________________________

CONTACT NAME: ____________________________________________________________

Please include copies of the patient’s insurance/drug benefit cards (front and back) .

CLINICAL INFORMATION

ADDRESS: ______________________________________________________________

PHONE: _________________________________

FAX: ___________________________

PRIMARY INSURANCE: _______________________________________ RELATIONSHIP:

SELF

SPOUSE

CHILD

POLICY #: __________________________________

SUITE #: ____________________CITY: ______________________________________

STATE: _________________________________

ZIP: ___________________________

OTHER INSURANCE: _________________________________________ POLICY #: _____________________________ INSURANCE PHONE #: _______________________________

CLINICAL INFORMATION

Patient Diagnosis

Please Check All That Apply

–

CLINICAL INFORMATION

ALCOHOL DEPENDENCE:

OPIOID DEPENDENCE:





ICD-10: F10____________

ICD-10: F11____________





ICD-10: F10____________

ICD-10: F11____________





ICD-10: F10____________

ICD-10: F11____________





Other ICD10: ________________________

Other ICD10: ________________________

Patient has tried and failed the following medication(s): _________________________________________________________________________________________-

____________________________________________________________________________________________________________________________________

For OPIOID DEPENDENCE complete the following:

Is the patient opioid-free for at least 7-10 days based on testing (i.e. negative Naltrexone test,





urine drug screen, etc) prior to initiation of Vivitrol?

Yes

No





Is the patient participating in a comprehensive management program that provides psychosocial support?

Yes

No

For ALCOHOL DEPENDENCE complete the following:





Has the patient abstained from alcohol in the outpatient setting prior to initiation of Vivitrol?

Yes

No





Is the patient actively consuming alcoholic beverages at this time?

Yes

No



Patient’s First Injection Date (Required by Insurance Plan):___/____/____

Check this box if patient is restarting therapy

PRESCRIPTION INFORMATION

Please check and complete accordingly:



CLINICAL INFORMATION

VIVTROL 380 mg vial, Sig: Inject 380 mg IM q4 weeks

Dispense: Qty # 1 vial for a 28 day supply

Refill ______ times



VIVTROL 380 mg Vial, Other Sig and Dispense Qty:__________________________________________________________________Refill ____times

______________________________________

_____________________________________

Prescriber’s Signature

Date:

Substitution Allowed







Deliver Medication to:

Prescriber’s Office

Injection Site Address

Other:_____________________________

By signing below, I authorize Acro Pharmaceutical Services (“Acro”) to: Collect my health condition and prescription information from my doctor, healthcare provider, health

insurer or pharmacist in order to ensure its accuracy and completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the “Program”); and

contact my insurer, other potential funding sources, social workers, patient advocacy organizations, and patient assistance programs on my behalf to determine if I am eligible for

assistance. I hereby authorize my doctor, healthcare provider, health insurer or pharmacist to provide my health condition and prescription information to Acro and to the Program. I

Patient’s Signature:

_______________

understand that I may revoke this authorization at anytime by sending a letter to Acro at 313 Henderson Drive, Sharon Hill, PA 19079.

NOTE TO HEALTHPLAN: PLEASE FAX AUTHORIZED REQUEST TO ACRO FOR DISPENSING AT (877) 381-3806

By signing below, I authorize Acro Pharmaceutical Services (“Acro”) to: Collect my health condition and prescription information from my doctor, healthcare provider, health

insurer or pharmacist in order to ensure its accuracy and completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the “Program”); and

Important Notice: This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for delivering

contact my insurer, other potential funding sources, social workers, patient advocacy organizations, and patient assistance programs on my behalf to determine if I am eligible for

the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please reply

assistance. I hereby authorize my doctor, healthcare provider, health insurer or pharmacist to provide my health condition and prescription information to Acro and to the Program. I

to the sender that you have received the message in error and destroy this copy.

Patient’s Signature:

_______________

understand that I may revoke this authorization at anytime by sending a letter to Acro at 313 Henderson Drive, Sharon Hill, PA 19079.

Important Notice: This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for delivering

the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please reply

to the sender that you have received the message in error and destroy this copy.