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Expanded Coverage for Naltrexone Long-Acting Injections

October 28, 2016

While remaining available to all Medi-Cal beneficiaries as a medical benefit, naltrexone long acting injections are also currently available as a pharmacy benefit to Medi-Cal beneficiaries meeting the following guidelines:

  1. The beneficiary is charged with, or convicted of, a felony or misdemeanor; and
  2. The beneficiary is monitored for compliance with the terms and conditions of county or state supervision (including but not limited to probation, parole, 1210 PC, mandatory supervision, post-release community supervision or pretrial release), including substance abuse monitoring.

Beginning on November 1, 2016, the pharmacy benefit coverage will be expanded to include beneficiaries receiving treatment at Local Specialty Mental Health Plans (LSMHP) sites of care which includes county mental health or behavioral health departments and/or associated contracted providers.

The provision of naltrexone long acting injections must be in accordance with United States Food and Drug Administration (FDA) guidelines for the treatment of alcohol use disorder and the prevention of relapse in opioid use disorder following opioid detoxification. Naltrexone long acting injections are given intramuscularly once every four weeks at a dose of 380 mg.

The following guidelines outline the processes for providing naltrexone long acting injection and submitting the claim as either a medical claim for all Medi-Cal beneficiaries or as a pharmacy claim for select populations as indicated below.

Medical Claims
The policy for naltrexone long-acting injection, when provided as a medical benefit, can be found in the Injections: Drugs N – R Policy section of the Medi-Cal Part 2 provider manual.

Pharmacy Claims
Naltrexone long-acting injections are available as a pharmacy benefit to Medi-Cal beneficiaries meeting the following criteria:

  1. The beneficiary is receiving specialty mental services from practitioners under contract or employed by the Local Specialty Mental Health Plan as a necessary component of treatment.

or

  1. The beneficiary is charged with, or convicted of, a felony or misdemeanor, and monitored for compliance with the terms and conditions of county or state supervision (including but not limited to probation, parole, 1210 PC, mandatory supervision, post-release community supervision or pretrial release), including substance abuse monitoring.

Naltrexone long-acting injections require a Treatment Authorization Request (TAR).