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Naltrexone Expanded to Full-Scope Pharmacy Benefit

November 21, 2017

Effective for dates of service on or after December 1, 2017, naltrexone for extended-release injectable suspension is expanded to a full-scope pharmacy benefit.

Naltrexone for extended-release injectable suspension(Vivitrol) is a pharmacy benefit currently available to Medi-Cal beneficiaries meeting the following criteria:

  1. Charged with, or convicted of, a felony or misdemeanor; and
  2. Monitored for compliance with terms and conditions of county or state supervision (including but not limited to probation, parole, Penal Code 1210, mandatory supervision, post-release community supervision or pretrial release), including substance abuse monitoring.
  3. Prescribed by practitioners under contract, or employed by, the Local Specialty Mental Health Plan as a necessary component of treatment.

On October 26, 2017, the federal administration declared a national public health emergency to combat the escalating opioid crisis. Medication-assisted treatment (MAT) is one tool in addressing the crisis. Therefore, beginning on December 1, 2017, the pharmacy benefit coverage of naltrexone for extended-release injectable suspension will be expanded to a full-scope pharmacy benefit.

The following guidelines outline the processes for providing naltrexone for extended-release injectable suspension and submitting the claim as either a medical claim or a pharmacy claim.

Medical Claims
The policy for naltrexone for extended-release injectable suspension, when provided as a medical benefit, can be found in the Injections: Drugs N – R Policy section of the appropriate Part 2 provider manual.

Pharmacy Claims
Naltrexone for extended-release injectable suspension is available as a pharmacy benefit to Medi-Cal beneficiaries who use the drug for one of the following:

  • The treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment. Patients should not be actively drinking at the time of initial administration
  • The prevention of relapse to opioid dependence, following opioid detoxification
  • Part of a comprehensive management program that includes psychosocial support

Selected alcohol and heroin detoxification and dependency treatment drugs, including naltrexone for extended-release injectable suspension, are noncapitated (carved out) for Managed Care Plans (MCPs). Naltrexone for extended-release injectable suspension must be billed as a fee-for-service claim for all Medi-Cal beneficiaries, including those enrolled in an MCP. Naltrexone for extended-release injectable suspension always requires a Treatment Authorization Request (TAR). Pharmacy claims for naltrexone extended-release injectable suspension are billed using the product National Drug Code (NDC).