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Vivitrol2gether enrollment form

Vivitrol enrollment form 2025

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The document is a patient enrollment form for VIVITROL, a medication used to treat alcohol and opioid dependence. It includes sections for prescriber and patient information, insurance details, diagnosis codes, prescription information, and patient authorization for the use and disclosure of health information. The form emphasizes the importance of completing all fields to avoid processing delays and provides instructions for submitting the form via fax. Additionally, it outlines important safety information regarding VIVITROL's indications, contraindications, warnings, and potential adverse reactions.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can a pharmacist give a VIVITROL injection?

VIVITROL must be prepared and administered by a healthcare provider.

Who can administer Vivitrol injections?

VIVITROL must be injected by a healthcare provider. Call your healthcare provider right away if you notice any of the following at any of your injection sites: intense pain. the area feels hard.

How much does one shot of Vivitrol cost?

The cost for Vivitrol 380 mg intramuscular powder for injection, extended release is around $1,774 for a supply of 1 powder for injections, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans.

How do I get a VIVITROL bracelet?

A VIVITROL pain management card, medical alert bracelet, or medical alert dog tags can be ordered by calling 1-800-VIVITROL (1-800-848-4876), option #3. You can also download a pain management card below.

What form does VIVITROL come in?

VIVITROL is an off-white to light tan powder for injectable suspension in a 5 mL single-dose vial. VIVITROL contains 380 mg of naltrexone in a microsphere formulation per vial (337 mg of naltrexone per gram of microspheres).

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Will insurance pay for VIVITROL?

For commercially insured patients, VIVITROL may be covered under the pharmacy benefit, medical benefit, or both. Providers and office staff, be sure to verify the patients insurance to confirm how VIVITROL is covered. Note that your patient may have a separate pharmacy (prescriptions) benefit.

Can a pharmacist give me an injection?

Pharmacists can administer a scheduled medicine by injection when dispensed on a prescription lawfully issued by a medical practitioner, dentist, nurse practitioner, midwife practitioner, endorsed nurse or midwife, optometrist or podiatrist.