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GETTING STARTED
PROGRAM OVERVIEW
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
DEDICATED CASE MANAGER SUPPORT
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL® (NALTREXONEFOREXTENDED-RELEASEINJECTABLESUSPENSION)
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MEDICATION GUIDEPRESCRIBING INFORMATION
WHAT’S INSIDE
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
MEDICATION GUIDEPRESCRIBING INFORMATION
PROGRAM OVERVIEW
Along with VIVITROL® (naltrexone for extended-release injectable suspension), we offer Vivitrol2getherSM—a customized support services program to help you and your patients in their recovery journey from opioid or alcohol dependence throughout fulfillment, transition of care, and during VIVITROL treatment.
WithVivitrol2gether,youchoosetheVIVITROLfulfillmentfeaturesthatworkbesttosupport
yourpatients.Ifyouprefertoworkdirectlywithpharmacies,weprovidetheresourcesyouneed,
withVIVITROLteammembersavailabletoansweryourquestionsquickly.Youcanalsochoose
tosignuptoworkwithadedicatedcasemanagertohelpassistyouinthefulfillmentprocess,as
wellasuseanonlinetrackingportaltofindVIVITROLfulfillmentdetailsandpatientservices.
Whichever option you choose, Vivitrol2gether provides the resources to support patient access:
§ Specialtyorotherpharmacyselectionoptionsbasedonapatient’shealthplancoverage
§ Educationabouthealthplanandpharmacyrequirements,includingpriorauthorizationsand
coveragerequirements
§ EasyaccesstoresourcestohelpfacilitateVIVITROLdelivery
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
PROGRAM OVERVIEW
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First VIVITROL prescription
§ Determinethespecialtyorotherpharmacyoptionsavailablebasedonthepatient’shealthplancoverage
§ DiscusstheVIVITROLCo-paySavingsProgramwiththepatient;eligiblepatientscansignupandprovidetherequiredinformationtothepharmacy
§ Remindyourpatientstoexpectacallfromthepharmacyand/ornursecoordinatortoreviewimportantinformationaboutthefirstpharmacyorder
Insurance, Co-pay Savings and Prescription Verification
§ Specialtyorotherpharmacyperformsabenefitverificationonbehalfofthepatientandconfirmsprescriptionverificationandpriorauthorizationwiththehealthplan
§ Co-paysavingsareappliedforeligiblepatients
§ Patientauthorizespayment
Schedule shipping and delivery
§ Patientiscontactedtoscheduleorconfirmdeliverydate
§ Patientiscalledaboutnextstepsandfollow-ups
Rx is filled and ready to ship
§ Pharmacycontactspatientandprovider’sofficetoauthorizeshipment
– Afterpatientauthorization,pharmacywillcontactyourofficetosetupdelivery
§ Prescriptionisfilledbypharmacyandshippedtoyouroffice
Delivery of VIVITROL
§ OfficereceivesVIVITROL
§ PatientreceivesinjectionofVIVITROL
§ Yourpatient’sfollow-upappointmentisscheduled
Follow-up for next injection
§ Schedulefollow-upappointmentforthenextinjection
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
Whetheryouhaveselectedtosendtheprescriptiondirectlytothepharmacy(specialtyorother)
orhavechosentoworkwithaVivitrol2getherdedicatedcasemanager,thefollowingsteps
provideanunderstandingoftheorderingprocessforVIVITROL.
Follow these steps with your patients to facilitate the delivery of VIVITROL to your office once a month.
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
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MEDICATION GUIDEPRESCRIBING INFORMATION
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
PATIENT SUPPORT SERVICES AND RESOURCES
§ An800 number for patientsconsideringVIVITROLtolearnaboutVIVITROL,howto
getstartedandwhat’snecessaryduringtreatment
§ A dedicated Nurse Coordinator,onceapatientisreceivingVIVITROLtreatment,whocan
providepatientsupportservicesduringtreatmentwithVIVITROL
§ Aidincoordinating carefromaresidentialfacilityorothersettingsforfollow-upVIVITROL
injection
§ Assistancewiththelogisticsof obtaining, starting, and scheduling VIVITROLtreatment
§ Help with finding counselorsandinpatientandoutpatientservicesintheirarea
§ InformationabouttheVIVITROL® Co-pay Savings Program,eligibilityrequirementsand
enrollmentinstructions
§ Online resourcesfortherecoveryjourney
§ Helparrangingappointments and follow-up reminders
The VIVITROL Provider Locator isanonlineresourcethatconnectspatientstohealthcare
providerswhocanprescribeand/oradministerVIVITROLnationally.
IfyouprovideVIVITROL,consideraddingyourfacilitytotheProviderLocatorsopatients
andreferringhealthcareprofessionalscanfindyou.Visit VIVITROL.com/Locator.
IfyouhavepatientstransitioningtoanewsiteofcareforVIVITROL,usethelocatortofind
VIVITROLprovideroptionsinaspecificareaaspartoftheirdischargeortransitionplan.
Visit VIVITROL.com to access these resources.
Your VIVITROL® (naltrexone for extended-release injectable suspension) patients also have the support of Vivitrol2getherSM. We understand the recovery journey from opioid or alcohol dependence is a challenge. Vivitrol2gether provides a variety of patient support services:
Provider Locator:
PATIENT SUPPORT SERVICESANDRESOURCES
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—Kurt,father,counselor,recoveringopioidaddict*
I’m choosing to move forward, and if there’s something out there that’s going to help me, then I’m going to use it.
*Patientstoriesreflectpersonalexperiences.Individualexperiencesmayvary.
Watch Kurt’s story on VIVITROL.com/Kurt to learn how he used VIVITROL along with a drug counseling program to help reinforce his recovery process.
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
MEDICATION GUIDEPRESCRIBING INFORMATION
ORDERING FOR YOUR PATIENTS
VIVITROL® (naltrexone for extended-release injectable suspension) is widely accessible for your patients
Pharmacyoptions,approvalrequirements,andthe
costforVIVITROLprescriptionsvarybyhealthplan.
HealthplanstypicallycoverVIVITROLaseithera
medicalorpharmacybenefit.TheVivitrol2getherSM
teamwilllookintoyourpatient’shealthplancoverage
andcommunicateanyrequirements.
§ Network pharmacy:SomehealthplansallowanynetworkpharmacytofillVIVITROL
§ Specialty pharmacy: Often,healthinsuranceprovidersallowpatientstoobtaininjectable
medicationsthroughaspecialtypharmacy.Thesepharmacieswillobtainandshipapatient-
specificprescriptiontoyouroffice.Theybillthepatient’sinsurancedirectlyandcollectany
co-payfromthepatient.Ifapatient’sinsurancecoversVIVITROLunderthemedicalbenefit
portionofthehealthplan,theplanmayallowanetworkpharmacytoshipVIVITROLdirectly
totheprovider’sofficeandbillthepatient’shealthplandirectlyonbehalfoftheprovider
§ Buy-and-bill: AnotheroptionifVIVITROLiscoveredthroughthemedicalbenefitisforthe
doctortobuyunitsofVIVITROLfromaspecialtydistributorandbillthepatient’sinsurance
directlywhenitisadministered
Pharmacy and fulfillment options
HowhealthcareprovidersobtainVIVITROLusuallydependsonhowitiscoveredbythepatient’s
healthplan.
Nationally more than 90%
of patients have insurance
coverage for VIVITROL1
Reference: 1. DataderivedfrominsuredpatientsenrolledintheVIVITROL®Co-paySavingsProgramfromMarch2016throughFebruary2017.
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
The Vivitrol2gether Enrollment Form gathersalltheinformationneededtoprocess
anorderincludingallpatientandprovidersignatures.Theform,alongwithother
necessarydocuments,isfaxedtoVivitrol2gethersotheteamcanhelpexpeditethe
approvalandshipmentprocess.(Seeformonpage9.)
These are the 3 primary resources you use when working with a dedicated case manager.
Viewthestatusofapatient’sprescriptionontheProvider Online Portal.Tosignup,
obtainthePortalAuthorizationFormfromyourofficecontactordirectlyfrom
Vivitrol2gether.Oncetheauthorizationisprocessed,youwillbeabletoviewupdates
onanyVIVITROLprescriptionsyousubmitted.
A dedicated Nurse Coordinatorwhoprovidespatientsupportservicestopatients
throughoutfulfillment,transitionofcare,andduringtreatmentwithVIVITROL.
Suggestions to speed up pharmacy fill timeItisimportanttotrytoavoid delaysinthefulfillmentofVIVITROL.
Submit any Prior Authorization Formstothehealthplanatthestartoftheprocess.Thepharmacycannotshipuntiltheyreceiveapprovalfromthehealthplan.
Create a connection with the pharmacy. Establishingarelationshipandcommunicatingurgencycanhelptoexpediteshipments.Determinethebestwayforyoutocommunicatewiththepharmacy(e.g.,phone,email,orfax).
Follow up with the pharmacy regularlyandbesuretocommunicatetherequiredinjectiondateforeachpatient.
View ordering steps on the following page.
ORDERINGFORYOURPATIENTS
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
DEDICATED CASE MANAGER SUPPORT
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MEDICATION GUIDEPRESCRIBING INFORMATION
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
VIVITROL prescription: CompleteandfaxallnecessaryformstoVivitrol2gether.Ifyour
patientsareeligible,*theycansignupfortheVIVITROL®Co-paySavingsProgramto
helpsaveonprescriptionout-of-pocketexpenses. (Seepage8forfulldetails.)
How Vivitrol2gether Can Help: Vivitrol2gether will provide you with pharmacy options
(specialty or other) based on your patient’s health plan and Vivitrol2gether pharmacy
experience. If you have a preferred pharmacy, include it on the Vivitrol2gether Enrollment
Form for triage. Vivitrol2gether may also assist in determining the proper Prior
Authorization Form for a specific payer.
Prescription processing: OncetheVivitrol2getherEnrollmentFormisenteredintothe
pharmacydatabase,thepharmacyperformsabenefitverificationonbehalfofyour
patientsandconfirmspriorauthorizationapprovalwiththehealthplan(ifapplicable).
How Vivitrol2gether Can Help: If information is missing, Vivitrol2gether can
troubleshoot and coordinate the retrieval of missing information. If there are any obstacles
at this stage, Vivitrol2gether informs you as it helps get the prescription back on track.
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*Toseefulleligibilityrequirements,pleaserefertopage8.
To authorize patient enrollment for Vivitrol2gether, 4 signatures are required on the enrollment form.
§ 1 signature from the provider § 3 signatures from the patient
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Follow these steps for ordering VIVITROL® (naltrexone for extended-release injectable suspension), and learn how a dedicated Vivitrol2getherSM case manager can help.
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
Next Steps Card: ReviewtheinformationontheNextStepsCardwithyourpatients
andhandthecardtothem.RemindyourpatientsthataNurseCoordinatorand
pharmacistwillbecallingtoreviewimportantinformationaboutthefirstpharmacy
order.Itisimportantthattheyanswerthesecalls.
How Vivitrol2gether Can Help: Vivitrol2gether provides a dedicated Nurse Coordinator
for every patient who signs up. Nurse Coordinators can help guide patients through the
process of starting and continuing VIVITROL treatment.
Shipment authorization: Thepharmacywillneedtocallyourpatients—eventhose
stayinginaresidentialfacility—toauthorizeshipmentbeforesettingupdeliveryto
yourlocation.Onthecall,patientsmaybeaskedto:
§ Authorizeshipment
§ GivetheirVIVITROL®Co-paySavingsProgramID#
§ Provideacreditcard#foranyco-payresponsibility
Once patients have authorized shipment, the pharmacy will contact your office to set up VIVITROL delivery.
Without this authorization, VIVITROL will not be shipped. If patients are residential
and do not have phone access, the pharmacy will be notified, but they will still attempt to
reach patients. Have a process in place to get patients in contact with their pharmacy.
How Vivitrol2gether Can Help: Nurse Coordinators will attempt to reach your patients
and their authorized contact(s) when the prescription is ready to ship. They also remind
patients of their injection appointment dates and times. If there are obstacles at this stage,
Vivitrol2gether informs you and troubleshoots to get the prescription back on track.
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DEDICATED CASE MANAGER SUPPORT (CONTINUED)
ORDERINGFORYOURPATIENTS
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
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MEDICATION GUIDEPRESCRIBING INFORMATION
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
CONTINUING PATIENT CARE
§ When filling their first prescription ofVIVITROL,patientsarerequiredtoworkwithyoutofillout
theappropriateVivitrol2getherSMforms.It’simportantto:
ReviewtheNext Steps Cardwithyourpatient.
Askthepatienttoaddaminimumof2 authorized contacts forVivitrol2getherandthepharmacy.
Informyourpatientsthat they will receive a phone callfromthespecialtyspecialtyorotherpharmacyforapprovaltoshipVIVITROL.
§ Patients need to authorize the shipment of their prescription to ensure it gets to your office,
for every appointment. BecauseyourofficeisnotacquiringVIVITROLdirectlyandVIVITROLis
beingbilledtothepatient,thepharmacywillalsohavetocollectanyout-of-pocketexpenses.It’s
importanttoemphasizethiscommunication,aspharmacieshavereportedthatreachingpatients
toauthorizeshipmentisachallenge.
§ If patients are transitioning to an outpatient program andthepresentfacilityisnotwherethey
willreceivefutureVIVITROLinjections,workwiththemtocreateadischargeplanandfindan
injectionprovider.Vivitrol2getherwillcoordinatewiththepharmacyandtheintendedinjection
providertoensuretheprescriptionisdeliveredtothecorrectlocation.
To support your patients on their recovery journey with VIVITROL® (naltrexone for extended-release injectable suspension), it’s important they’re aware of the following:
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
Schedule their next appointment: Yourpatientshouldunderstandyourscheduling
proceduresandanyactionneededtoschedulethenextappointment.
Stay in touch with their Nurse Coordinator: UponenrollinginVivitrol2gether,your
patientwillbeassignedaVIVITROLNurseCoordinator.TheassignedNurse
Coordinatorwillhelpcoordinatetheirfirstinjectionandwillcontinuetoworkwith
themduringVIVITROLtreatment.NurseCoordinatorswillprovideinjection
appointmentremindersandfollow-upcalls.Itisimportanttoremindyourpatientsto
alwaysreturntheirNurseCoordinator’scalls.
Continue psychosocial support: Yourpatientsshouldcontinuereceivingcounseling
supporttohelpthemworkthroughtheirrecoveryjourneywhiletheyareonVIVITROL.
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Always remind your patients to:
Nurse Coordinators will contact patients within a week of receiving a completed Vivitrol2gether Enrollment Form from your office. Patients can call 1-800-VIVITROL (1-800-848-4876) 9am–8pm (EST) to reach their Nurse Coordinator.
CONTINUINGPATIENT CARE
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
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CO-PAY SAVINGSPROGRAM
* Eligibility for Alkermes-Sponsored Co-pay Assistance: OffervalidonlyforprescriptionsforFDA-approvedindications.Patientsmustbeatleast18yearsold.IfpatientsarepurchasingtheirVIVITROLprescriptionswithbenefitsfromMedicare,includingMedicarePartDorMedicareAdvantageplans;Medicaid,includingMedicaidManagedCareorAlternativeBenefitPlans(“ABPs”)undertheAffordableCareAct;Medigap;VeteransAdministration(“VA”);DepartmentofDefense(“DoD”);TRICARE®;oranysimilarstate-fundedprogramssuchasmedicalorpharmaceuticalassistanceprograms,theyarenoteligibleforthisoffer.Voidwhereprohibitedbylaw,taxed,orrestricted.Alkermes,Inc.reservestherighttorescind,revoke,oramendtheseofferswithoutnotice.
†DataderivedfrominsuredpatientsenrolledintheVIVITROL®Co-paySavingsProgramfromMarch2016throughFebruary2017.
The VIVITROL® (naltrexoneforextended-releaseinjectable
suspension) Co-pay Savings Program
TheVIVITROL®Co-paySavingsProgramispartofthecomprehensivepatientsupport
servicesfromVivitrol2getherdesignedtohelpyoureligiblepatients*without-of-pocket
expensesassociatedwiththeirVIVITROLprescriptions.
The VIVITROL® Co-pay Savings Program:
§ Coversupto$500/monthofVIVITROLco-payordeductibleexpensesforeligiblepatients.*
Thismaymean$0co-payordeductibleexpensesforyourpatients.
§ Hasnoincomeeligibilityrequirements.
§ Hasnopresetdurationlimitsorexpiration.TheVIVITROL®Co-paySavingsProgramcardcanbe
usedmultipletimes.Itneverexpiresandremainsactivethroughoutthedurationoftreatment.
§ Allowspatientstoprintco-paycardsdirectlyfromVIVITROLCopay.com.Patientscancutoutthe
cardandkeepitintheirwallet,sothattheyalwayshavetheirIDnumberhandytogivetoa
healthcareproviderorpharmacy.
90%† of insured patients using the program had no
out-of-pocket expenses for VIVITROL.†
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
Who is eligible*?
AnypatientwithaprescriptionforVIVITROLforalcoholoropioiddependence
whois18yearsorolderwith:
§ Commercialhealthinsurance
§ Noinsuranceorelectingnottouseinsurance
Who is not eligible?
PatientsusingfederalorstatehealthcareprogramstopurchasetheirVIVITROL
prescription,suchas:
§ Medicare,includingMedicarePartDorMedicareAdvantageplans–Medicaid,
includingMedicaidManagedCareorAlternativeBenefitPlansunderthe
AffordableCareAct
§ Medigap
§ VeteransAdministration
§ DepartmentofDefense
§ TRICARE®
§ State-fundedprogramssuchasmedicalorpharmaceuticalassistanceprograms
Additional Financial Assistance OptionsIf your patient is unable to cover a co-pay for VIVITROL or has no insurance, Vivitrol2gether may be able to help identify additional financial assistance options. Please contact Vivitrol2gether for more information.
Your eligible patients* can sign up for the VIVITROL® Co-pay Savings Program by visiting VIVITROLCopay.com
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
CO-PAYSAVINGSPROGRAM
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
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MEDICATION GUIDEPRESCRIBING INFORMATION
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
Fax ALL of the following documents to Vivitrol2gether Support Services at 1-877-329-8484:
§Vivitrol2getherSupportServicesEnrollmentForm
§Photocopyofthefrontandbackofthepatient’sinsurancecard(enlargedtoensurelegibility)
§PriorAuthorizationForm(ifapplicable)
EResidential facilities, enter your patient’s next provider followingdischarge.ThisallowsthepharmacyandNurseCoordinatortocoordinateduringtreatment.
§Besureyourpatientunderstandsyourdischargeplanforcontinuedtreatment.
Ifyoudon’tknowwhothenextproviderwillbe,Vivitrol2gethercanhelpyoulocateone.
BEnter a working phone number for your patient.Thepharmacytypicallymustspeakwithyourpatienttoauthorizeshipment.Patientsinresidentialfacilitieswillalsoneedtobereachablebythepharmacy.Includeinformationforalternatecontactsinsection7incasethepatientisunavailable.
COutpatientproviderswhowillbeadministeringinjectionsgoingforward,select“yes.”
DFillintheestimateddischargedatetoensuretimelycoordinationduringtreatment.
FInclude an enlarged copy of your patient’s insurance card (front and back)orfilloutthissection. The card copy is preferred. Pharmacyselectionandprocessingcannottakeplacewithoutyourpatient’shealthplaninformation.
GProvide your signature ontheEnrollmentFormtoverifyyouasthehealthcareproviderprescribingVIVITROL.
PATIENT ENROLLMENT FORM
CO-PAY SAVINGS PROGRAM
PATIENTENROLLMENTFORM
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients. MEDICATION GUIDEPRESCRIBING INFORMATION
PATIENTENROLLMENTFORM: FRONT PAGE
ItisimportanttotrytoavoiddelaysinVIVITROL®(naltrexoneforextended-releaseinjectable
suspension)fulfillmentforyourpatients.Takingthetimewithyourpatienttocompletethe
Vivitrol2getherSMEnrollmentFormandcheckoffallthesestepswillconfirmaccuracyandhelp
yourpatientwithanybarrierstoreceivingVIVITROL.
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
An editable PDF version of the Vivitrol2gether Support Services patient enrollment form can be downloaded at VIVITROLHCP.com/Support.
Complete all fields to avoid delays in your treatment plan
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PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
PATIENTENROLLMENTFORM
All fields on this page must be filled out with your patient and require your patient’s name and signature.
KYour patient must check both boxes and sign and date the co-pay sectiontoconfirmeligibilityandinterestintheVIVITROL®Co-paySavingsProgram.*If missing, the prescription request will be sent to the specialty or other pharmacy without a co-pay card included. YoucanalsoenrollyourpatientonlineatVIVITROLCopay.com.Ifyourpatienthasaco-paycardalready,includethecardID#wherenoted.Patientsignatureisrequiredifeligible.
IIncluding two contacts will help expedite the process.Theseindividualswillbecontactedifthepatientisnotavailableorifthepatient’sphonenumberhaschanged.
JPatient authorization including signature, print name, and date are required for the enrollment to process. Amissingsignaturewilldelayprocessing.
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ItisimportanttotrytoavoiddelaysinVIVITROL®(naltrexoneforextended-releaseinjectable
suspension)fulfillmentforyourpatients.Takingthetimewithyourpatienttocompletethe
Vivitrol2getherSMEnrollmentFormandcheckoffallthesestepswillconfirmaccuracyandhelp
yourpatientwithanybarrierstoreceivingVIVITROL.
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
Helpful Hint:
To enroll, 4 signatures are required on this form
§ 1 from you (bottom of front page)
§ 3 from your patient
Complete all fields to avoid delays in your treatment plan
PATIENTENROLLMENTFORM: BACK PAGE
MEDICATION GUIDEPRESCRIBING INFORMATION
*Toseefulleligibilityrequirements,pleaserefertopage8.
An editable PDF version of the Vivitrol2gether Support Services patient enrollment form can be downloaded at VIVITROLHCP.com/Support.
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Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
FREQUENTLY ASKEDQUESTIONS
FREQUENTLY ASKEDQUESTIONS
How long does it take for a pharmacy to fill VIVITROL® (naltrexoneforextended-releaseinjectablesuspension)?
Pharmacyandhealthplanapprovaltimesvary:theycanshipasquicklyas48hoursortakeaslongas
2weeks.Asyoustarttoenrollpatients,youwillstarttobetterunderstandthetimingofthepharmacies
youworkwith.
How can I help expedite the prescription fill process?
Yourofficehasaroleinexpeditingaprescription.Belowaretipsthatcanhelp:
§Submit a complete Vivitrol2getherSM Enrollment Form. Besuretoincludeanenlargedfront-and-back
copyofthepatient’sinsurancecard,patientauthorization,andaminimumoftwoauthorizedcontacts
forthepatient.
§Complete any health plan Prior Authorization Form andsubmitittothehealthplanatthebeginningof
theprocess.Vivitrol2getheroryourofficecontactcanprovidegeneralhealthplancoverageinformation
andcopiesofPriorAuthorizationFormstoyourofficeifneeded.
§Follow up with the pharmacy. WhileVivitrol2getherwillworkonpharmacyfollow-up,itisabestpractice
forproviderstoalsocontactthepharmacy.Vivitrol2getherwillsendyouafaxalertwhenyourpatient’s
prescriptionhasbeensenttoapharmacy.Thisfaxwillincludethepharmacy’snameandphonenumber.
Youcancontactthepharmacytorequestthattheyexpeditetheprescription.
Why does the pharmacy need to speak with my patient to ship VIVITROL?
PharmaciesdeliveringVIVITROLhaveinternalprocessesorexternalaccreditationguidelinesrequiringpatient
authorizationtobilltheirinsurance.BecauseyourofficeisnotacquiringVIVITROLdirectlyandVIVITROLis
beingbilledtothepatient,thepharmacywillalsohavetocollectanyco-pay.Pharmacies have reported that
reaching patients to authorize shipment is a challenge.
Whatyoucando:
§GiveyourpatienttheprovidedNextStepsCard,containingimportantinformationaboutall
necessaryactions.Includeaworkingphonenumberforthepatientonimportantforms,includingthe
Vivitrol2getherEnrollmentForm.
§Askthepatienttoaddaminimumof2authorizedcontactsforVivitrol2getherandthepharmacy.
§ Informyourpatientsthattheywillbecalledbythespecialtypharmacy.Thepharmacyneedsthepatient’s
approvalbeforetheyshipVIVITROL.
Are there services for patients to learn more about VIVITROL (before patient enrollment)?
Yes,thereisan800 number for patientswhoareconsideringVIVITROLtocallforanswerstoquestions
aboutVIVITROL,howtogetstarted,andwhat’snecessaryduringtreatment.
Work directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your patients. Call 1-800-VIVITROL (1-800-848-4876), 9am–8pm (EST) and visit VIVITROLHCP.com to access a variety of helpful resources.
Please see Important Safety Information on page 12. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your patients. MEDICATION GUIDEPRESCRIBING INFORMATION
Office staff notes:
11
PATIENT SUPPORT SERVICES AND RESOURCES
ORDERING FOR YOUR PATIENTS
CONTINUING PATIENT CARE
CO-PAY SAVINGS PROGRAM
PATIENT ENROLLMENT FORM
FREQUENTLY ASKED QUESTIONS
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
PROGRAM OVERVIEW
IMPORTANT SAFETY INFORMATION FOR VIVITROL® (NALTREXONE FOR EXTENDED-RELEASE INJECTABLE SUSPENSION)
Please see Prescribing Information and Medication Guide. Review the Medication Guide with your patients.
IMPORTANT SAFETY INFORMATION FOR VIVITROL®
12
MEDICATION GUIDEPRESCRIBING INFORMATION
INDICATIONSVIVITROL is indicated for:
§TreatmentofalcoholdependenceinpatientswhoareabletoabstainfromalcoholinanoutpatientsettingpriortoinitiationoftreatmentwithVIVITROL.PatientsshouldnotbeactivelydrinkingatthetimeofinitialVIVITROLadministration.
§Preventionofrelapsetoopioiddependence,followingopioiddetoxification.
§VIVITROLshouldbepartofacomprehensivemanagementprogramthatincludespsychosocialsupport.
CONTRAINDICATIONS
VIVITROL is contraindicated in patients:
§Receivingopioidanalgesics
§Withcurrentphysiologicopioiddependence
§ Inacuteopioidwithdrawal
§Whohavefailedthenaloxonechallengetestorhaveapositiveurinescreenforopioids
§Whohaveexhibitedhypersensitivitytonaltrexone,polylactide-co-glycolide(PLG),carboxymethylcellulose,oranyothercomponentsofthediluent
WARNINGS AND PRECAUTIONSVulnerability to Opioid Overdose:
§Afteropioiddetoxification,patientsarelikelytohaveareducedtolerancetoopioids.VIVITROLblockstheeffectsofexogenousopioidsforapproximately28daysafteradministration.Astheblockadewanesandeventuallydissipatescompletely,useofpreviouslytolerateddosesofopioidscouldresultinpotentiallylife-threateningopioidintoxication(respiratorycompromiseorarrest,circulatorycollapse,etc.).
§Casesofopioidoverdosewithfataloutcomeshavebeenreportedinpatientswhousedopioidsattheendofadosinginterval,aftermissingascheduleddose,orafterdiscontinuingtreatment.Patientsandcaregiversshouldbetoldofthisincreasedsensitivitytoopioidsandtheriskofoverdose.
§AlthoughVIVITROLisapotentantagonistwithaprolongedpharmacologicaleffect,theblockadeproducedbyVIVITROLissurmountable.Theplasmaconcentrationofexogenousopioidsattainedimmediatelyfollowingtheiracuteadministrationmaybesufficienttoovercomethecompetitivereceptorblockade.Thisposesapotentialrisktoindividualswhoattempt,ontheirown,toovercometheblockadebyadministeringlargeamountsofexogenousopioids.
§AnyattemptbyapatienttoovercometheVIVITROLblockadebytakingopioidsmayleadtofataloverdose.Patientsshouldbetoldoftheseriousconsequencesoftryingtoovercometheopioidblockade.
Injection Site Reactions:
§VIVITROLinjectionsmaybefollowedbypain,tenderness,induration,swelling,erythema,bruising,orpruritus;however,insomecasesinjectionsitereactionsmaybeverysevere.
§ Injectionsitereactionsnotimprovingmayrequirepromptmedicalattention,including,insomecases,surgicalintervention.
§ Inadvertentsubcutaneous/adiposelayerinjectionofVIVITROLmayincreasethelikelihoodofsevereinjectionsitereactions.
§Selectproperneedlesizeforpatientbodyhabitus,anduseonlytheneedlesprovidedinthecarton.
§Patientsshouldbeinformedthatanyconcerninginjectionsitereactionsshouldbebroughttotheattentionoftheirhealthcareprovider.
Precipitation of Opioid Withdrawal:
§Whenwithdrawalisprecipitatedabruptlybyadministrationofanopioidantagonisttoanopioid-dependentpatient,theresultingwithdrawalsyndromecanbesevere.Somecasesofwithdrawalsymptomshavebeensevereenoughtorequirehospitalization,andinsomecases,managementintheICU.
§Topreventoccurrenceofprecipitatedwithdrawal,opioid-dependentpatients,includingthosebeingtreatedforalcoholdependence,shouldbeopioid-free(includingtramadol)beforestartingVIVITROLtreatment:
–Anopioid-freeintervalofaminimumof7–10daysisrecommendedforpatientspreviouslydependentonshort-actingopioids.
–Patientstransitioningfrombuprenorphineormethadonemaybevulnerabletoprecipitatedwithdrawalforaslongastwoweeks.
§ Ifamorerapidtransitionfromagonisttoantagonisttherapyisdeemednecessaryandappropriatebythehealthcareprovider,monitorthepatientcloselyinanappropriatemedicalsettingwhereprecipitatedwithdrawalcanbemanaged.
§Patientsshouldbemadeawareoftheriskassociatedwithprecipitatedwithdrawalandbeencouragedtogiveanaccurateaccountoflastopioiduse.
Hepatotoxicity:
§CasesofhepatitisandclinicallysignificantliverdysfunctionhavebeenobservedinassociationwithVIVITROL.Warnpatientsoftheriskofhepaticinjury;advisethemtoseekhelpifexperiencingsymptomsofacutehepatitis.DiscontinueuseofVIVITROLinpatientswhoexhibitacutehepatitissymptoms.
Depression and Suicidality:
§Alcohol-andopioid-dependentpatientstakingVIVITROLshouldbemonitoredfordepressionorsuicidalthoughts.Alertfamiliesandcaregiverstomonitorandreporttheemergenceofsymptomsofdepressionorsuicidality.
When Reversal of VIVITROL Blockade Is Required for Pain Management:
§ForVIVITROLpatientsinemergencysituations,suggestionsforpainmanagementincluderegionalanalgesiaoruseofnon-opioidanalgesics.IfopioidtherapyisrequiredtoreversetheVIVITROLblockade,patientsshouldbecloselymonitoredbytrainedpersonnelinasettingstaffedandequippedforCPR.
Eosinophilic Pneumonia:
§Casesofeosinophilicpneumoniarequiringhospitalizationhavebeenreported.Warnpatientsoftheriskofeosinophilicpneumoniaandtoseekmedicalattentioniftheydevelopsymptomsofpneumonia.
Hypersensitivity Reactions:
§Patientsshouldbewarnedoftheriskofhypersensitivityreactions,includinganaphylaxis.
Intramuscular Injections:
§AswithanyIMinjection,VIVITROLshouldbeadministeredwithcautiontopatientswiththrombocytopeniaoranycoagulationdisorder.
Alcohol Withdrawal:
§UseofVIVITROLdoesnoteliminatenordiminishalcoholwithdrawalsymptoms.
ADVERSE REACTIONS
§SeriousadversereactionsthatmaybeassociatedwithVIVITROLtherapyinclinicaluseincludesevereinjectionsitereactions,eosinophilicpneumonia,seriousallergicreactions,unintendedprecipitationofopioidwithdrawal,accidentalopioidoverdose,anddepressionandsuicidality.
§TheadverseeventsseenmostfrequentlyinassociationwithVIVITROLtherapyforalcoholdependence(ie,thoseoccurringin≥5%andatleasttwiceasfrequentlywithVIVITROLthanplacebo)includenausea,vomiting,injectionsitereactions(includinginduration,pruritus,nodules,andswelling),musclecramps,dizzinessorsyncope,somnolenceorsedation,anorexia,decreasedappetiteorotherappetitedisorders.
§TheadverseeventsseenmostfrequentlyinassociationwithVIVITROLinopioid-dependentpatients(ie,thoseoccurringin≥2%andatleasttwiceasfrequentlywithVIVITROLthanplacebo)werehepaticenzymeabnormalities,injectionsitepain,nasopharyngitis,insomnia,andtoothache.
You are encouraged to report side effects to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
ALKERMES and VIVITROL are registered trademarks of Alkermes, Inc. Vivitrol2gether is a service mark of Alkermes, Inc. ©2017 Alkermes, Inc. All rights reserved. VIV-003344
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