Medical Policy: 05.01.13
Original Effective Date: September 2006
Reviewed: June 2017
Revised: June 2017
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
The intent of the Vivitrol (naltrexone for extended-release injectable suspension) drug policy is to ensure appropriate selection of patients for therapy based on product labeling, clinical guidelines and clinical studies.
Vivitrol (naltrexone for extended-release injectable suspension) is a long acting opioid antagonist given once monthly by intramuscular injection. It is approved by the Food and Drug Administration (FDA) for the following indications:
- Treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to receiving treatment
- Prevention of relapse to opioid dependence following opioid detoxification
Not applicable
Injectable extended-release naltrexone (Vivitrol™) is considered not medically necessary for all applications because there is a similar and less expensive form of the drug available for oral administration.
Naltrexone is an opioid antagonist reported to reduce the cravings for opioids and alcohol in dependant patients; it does not diminish or prevent withdrawal symptoms. It also does not ensure abstinence from alcohol and opioids; it may, however, decrease patients' motivation to continue utilizing these substances by blocking some of their reinforcing effects.
The Guidelines for Psychosocially Assisted Pharmacological Treatment of Opioid Dependence recommend naltrexone in the prevention of relapse following detoxification. Consensus guidelines from the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Health indicate treatment with naltrexone decreases relapses to heavy drinking by curbing alcohol consumption.
Extended-release injectable naltrexone was developed in an effort to address the non-adherence that occasionally occurs with daily oral pharmacotherapy. However, there is no evidence demonstrating significant improvements in remission rates for both opioid and alcohol dependence in patients receiving the injectable formulation in comparison to those receiving the oral formulations.
Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.
*CPT® is a registered trademark of the American Medical Association.