Medical Policy Revision: Vivitrol® (naltrexone extended-release) Injection

Effective August 28, 2017, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for the injectable, long-acting form of naltrexone, Vivitrol^®.

Our revised medical policy, Vivitrol (naltrexone extended-release) Injection, identifies when this drug is considered medically necessary and when it is considered not medically necessary or investigational.

Review this revised policy in our Medical Policy Manual.

Based on the guidelines of our revised medical policy, Vivitrol^® (naltrexone extended-release) Injection, and the submitted diagnosis code(s), HCPCS code J2315 submitted on claims for services provided on and after August 28, 2017 may be denied as not medically appropriate for the submitted diagnosis.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after August 28, 2017.

Vivitrol^® is a registered trademark of Alkermes, Inc.