VIVITROL is indicated for:

The treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration.
The prevention of relapse to opioid dependence, following opioid detoxification.

VIVITROL should be part of a comprehensive management program that includes psychosocial support.

Get your patient’s card today in just 3 steps:

1

Confirm your patient’s eligibility

Is your patient 18 years or older?

What type of insurance will your patient use to pay for their VIVITROL prescription (select all that apply)?

Note: Patients using federal or state healthcare programs to purchase their VIVITROL prescription are not eligible.

Commercial health insurance purchased through your employer or purchased personally, and which does not include the other insurance types listed below

No insurance/cash paying

Medicare, including Medicare Part D or Medicare Advantage plans

Medicaid, including Medicaid Managed Care and Alternative Benefit Plans (“ABPs”) under the Affordable Care Act

Medigap

Veterans Administration (“VA”)

Department of Defense (“DoD”)

TRICARE

State-funded programs such as medical or pharmaceutical assistance programs and residential correctional programs

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2

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Your patient’s contact information

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By submitting this form, you are confirming that:

Your patient is 18 years or older
Your patient is not using any federal or state healthcare programs to pay for their VIVITROL prescription
Your patient has a valid VIVITROL prescription
You have provided the VIVITROL Co-pay Savings Program Terms and Conditions available at www.vivitrolcopayterms.com to the patient in either hard copy or digital form
You or others in your practice have obtained the patient’s authorization, where required by HIPAA, the Confidentiality of Substance Use Disorder Patient Records Regulation (42 C.F.R. Part 2), and/or other applicable privacy laws, to disclose the patient information above to the VIVITROL Co-pay Savings Program Administrator in order to support patient enrollment in the VIVITROL Co-pay Savings Program

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3

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91% of VIVITROL^®^® prescriptions for patients in the Co-pay Savings Program cost $0 out of pocket¹

Who is eligible for the Co-pay Savings Program?

Patients who:

Are 18 years or older
Have a valid prescription for VIVITROL
Have commercial health insurance or pay with cash

If your patients are covered by federal or state healthcare programs, they are not eligible for the Co-pay Savings Program, but they may still receive coverage for their VIVITROL prescription.

*Terms and Conditions

Eligible patients who have commercial insurance or no insurance may pay as little as $0 per prescription of VIVITROL. Maximum savings per prescription is $500 up to 12 prescriptions per calendar year, with maximum savings up to $6,000 per calendar year. Patients’ out-of-pocket expenses may vary. Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs. Additional terms and conditions apply. Please see www.vivitrolcopayterms.com for full VIVITROL Co-pay Program Terms and Conditions.

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See Important Safety Information.

See Prescribing Information. Review Medication Guide with your patients.

Reference: 1. Data on file. Alkermes, Inc. Waltham, MA.

IMPORTANT SAFETY INFORMATION

VIVITROL^® is contraindicated in patients:

Receiving opioid analgesics
With current physiologic opioid dependence or in acute opioid withdrawal
Who have failed the naloxone challenge test or have a positive urine screen for opioids
Who have exhibited hypersensitivity to naltrexone, polylactide-co-glycolide (PLG), carboxymethylcellulose, or any other components of the diluent

VIVITROL^® is contraindicated in patients:

Receiving opioid analgesics
With current physiologic opioid dependence or in acute opioid withdrawal
Who have failed the naloxone challenge test or have a positive urine screen for opioids
Who have exhibited hypersensitivity to naltrexone, polylactide-co-glycolide (PLG), carboxymethylcellulose, or any other components of the diluent

Vulnerability to Opioid Overdose

After opioid detoxification, patients are likely to have a reduced tolerance to opioids. VIVITROL blocks the effects of exogenous opioids for approximately 28 days after administration. As the blockade wanes and eventually dissipates completely, use of previously tolerated doses of opioids could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc). Cases of opioid overdose with fatal outcomes have been reported in patients who used opioids at the end of a dosing interval, after missing a scheduled dose, or after discontinuing treatment.
Patients and caregivers should be told of this increased sensitivity to opioids and the risk of overdose.
Although VIVITROL is a potent antagonist with a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. The plasma concentration of exogenous opioids attained immediately following their acute administration may be sufficient to overcome the competitive receptor blockade. This poses a potential risk to individuals who attempt, on their own, to overcome the blockade by administering large amounts of exogenous opioids.
Any attempt by a patient to overcome the VIVITROL blockade by taking opioids may lead to fatal overdose. Patients should be told of the serious consequences of trying to overcome the opioid blockade.
Discuss the availability of naloxone for the emergency treatment of opioid overdose with the patient and caregiver, at the initial VIVITROL injection and with each subsequent injection. Strongly consider prescribing naloxone for the emergency treatment of opioid overdose.

Injection Site Reactions

VIVITROL must be prepared and administered by a healthcare provider and must ONLY be administered as a deep intramuscular gluteal injection.
Inadvertent subcutaneous/adipose layer injection of VIVITROL may increase the likelihood of severe injection site reactions. Select proper needle size for patient body habitus and use only the needles provided in the carton.
VIVITROL injections may be followed by pain, tenderness, induration, swelling, erythema, bruising, or pruritus; however, in some cases injection site reactions may be very severe.
Injection site reactions not improving may require prompt medical attention, including, in some cases, surgical intervention.
In the clinical trials, one patient developed an area of induration that continued to enlarge after 4 weeks, with subsequent development of necrotic tissue that required surgical excision.
Patients should be informed that any concerning injection site reactions should be brought to the attention of their healthcare provider.

Precipitation of Opioid Withdrawal

When withdrawal is precipitated abruptly by administration of an opioid antagonist to a patient with opioid dependence, the resulting withdrawal syndrome can be severe. Some cases have been severe enough to require hospitalization and/or management in the ICU.
To prevent occurrence of precipitated withdrawal, patients with opioid dependence, including those being treated for alcohol dependence, should be opioid-free (including tramadol) before starting VIVITROL treatment:
- An opioid-free interval of a minimum of 7–10 days is recommended for patients previously dependent on short-acting opioids.
- Patients transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for as long as 2 weeks.
If a more rapid transition from agonist to antagonist therapy is deemed necessary and appropriate by the healthcare provider, monitor the patient closely in an appropriate medical setting where precipitated withdrawal can be managed.
Patients should be made aware of the risk associated with precipitated withdrawal and be encouraged to give an accurate account of last opioid use, as precipitated opioid withdrawal has been observed in patients with alcohol dependence in circumstances where the prescriber had been unaware of the additional use of opioids or co-dependence on opioids.

Hepatotoxicity

Cases of hepatitis and clinically significant liver dysfunction have been observed in association with VIVITROL. Warn patients of the risk of hepatic injury and advise them to seek help if experiencing symptoms of acute hepatitis. Discontinue VIVITROL in patients who exhibit signs and symptoms of acute hepatitis.

Depression and Suicidality

Patients with alcohol dependence or opioid dependence taking VIVITROL should be monitored for depression or suicidal thoughts. Alert families and caregivers to monitor and report the emergence of symptoms of depression or suicidality.

When Reversal of VIVITROL Blockade Is Required for Pain Management

For VIVITROL patients in emergency situations, suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid therapy is required to reverse the VIVITROL blockade, patients should be closely monitored by trained personnel in a setting staffed and equipped for CPR.

Eosinophilic Pneumonia

Patients who develop dyspnea and hypoxemia should seek medical attention immediately. Consider the possibility of eosinophilic pneumonia in patients who do not respond to antibiotics.

Hypersensitivity Reactions including Anaphylaxis

Patients should be warned of the risk of hypersensitivity reactions, including anaphylaxis, and should be advised to seek immediate medical attention in a healthcare setting prepared to treat anaphylaxis should a hypersensitivity reaction occur. The patient should not receive any further treatment with VIVITROL.

Intramuscular Injections

As with any intramuscular injection, VIVITROL should be administered with caution to patients with thrombocytopenia or any coagulation disorder.

Alcohol Withdrawal

Use of VIVITROL does not eliminate nor diminish alcohol withdrawal symptoms.

Interference With Laboratory Tests

VIVITROL may be cross-reactive with certain immunoassay methods for the detection of drugs of abuse (specifically opioids) in urine. For further information, reference to the specific immunoassay instructions is recommended.

Adverse Reactions

The adverse events seen most frequently in association with VIVITROL therapy for alcohol dependence (occurring in ≥5% and at least twice as frequently with VIVITROL than placebo) include nausea, vomiting, injection site reactions (including induration, pruritus, nodules, and swelling), arthralgia, arthritis, or joint stiffness, muscle cramps, dizziness or syncope, somnolence or sedation, anorexia, decreased appetite or other appetite disorders.
The adverse events seen most frequently in association with VIVITROL in patients with opioid dependence (occurring in ≥2% and at least twice as frequently with VIVITROL than placebo) include hepatic enzyme abnormalities, injection site pain, nasopharyngitis, insomnia, and toothache.

INDICATIONS

VIVITROL is indicated for:

The treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration.
The prevention of relapse to opioid dependence, following opioid detoxification.

VIVITROL should be part of a comprehensive management program that includes psychosocial support.

For more information about VIVITROL, please see full Prescribing Information.

Reference: 1. Data on file. Alkermes, Inc. Waltham, MA.

VIVITROL^® Co-pay
Savings Program

Get your patient’s card today in just 3 steps:

1

Confirm your patient’s eligibility

Check eligibility

Sorry, your patient is not eligible. You can:

2

Sign up for the co-pay savings program

Get co-pay card

3

Give your patient their co-pay card

Get co-pay card

91% of VIVITROL^®^® prescriptions for patients in the Co-pay Savings Program cost $0 out of pocket¹

Request a rep

Explore services now

IMPORTANT SAFETY INFORMATION

IMPORTANT SAFETY INFORMATION

INDICATIONS

VIVITROL® Co-pay Savings Program

Get your patient’s card today in just 3 steps:

1

Confirm your patient’s eligibility

Check eligibility

Sorry, your patient is not eligible. You can:

2

Sign up for the co-pay savings program

Get co-pay card

3

Give your patient their co-pay card

Get co-pay card

91% of VIVITROL®® prescriptions for patients in the Co-pay Savings Program cost $0 out of pocket1

Request a rep

Explore services now

IMPORTANT SAFETY INFORMATION

IMPORTANT SAFETY INFORMATION

INDICATIONS

VIVITROL^® Co-pay
Savings Program

91% of VIVITROL^®^® prescriptions for patients in the Co-pay Savings Program cost $0 out of pocket¹