To submit a medical co-pay claim for VIVITROL® (naltrexone for extended-release injectable suspension) you need:
VIVITROL® Co-pay Savings Program Terms and Conditions
Eligibility for VIVITROL Co pay Savings Program (Program): This Program is only available to patients 18 years or older with a valid VIVITROL prescription.
This Program is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare (including Medicare Part D), Medicaid, Medigap, VA, DOD, TRICARE, or a residential correctional program. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this Program. Patients must live in the United States or Puerto Rico. Patients must meet the Program requirements every time they use the VIVITROL Co-pay Savings Card.
Program Benefit: Eligible patients may pay as little as $0 per prescription of VIVITROL. Maximum savings per prescription is $500.00 up to 12 prescriptions per calendar year, with maximum savings up to $6,000 per calendar year. After reaching the maximum Program benefit amounts, patients are responsible for any remaining out-of-pocket costs for VIVITROL. Eligible patients may receive benefits for valid claims submitted with a date of service that is up to 90 days prior to the initial enrollment date. The Program assists with the out-of-pocket cost for VIVITROL only. It does not assist with any other out-of-pocket costs (e.g., for the office visit or medication administration) even if such costs are associated with VIVITROL administration. All Program payments are for the benefit of the patient only. The VIVITROL Co-pay Savings Card expires after 5 years but may be renewed if all eligibility criteria are met.
Additional Terms of Use: This Program is not conditioned on any past, present, or future purchase, including refills. To use this Program, the participating patients are responsible for following any health plan requirements, including any requirements, if any, to inform the health plan how much co-payment support they get from this Program. This Program may be subject to health plan benefit design requirements. Alkermes may rescind, revoke, or amend this Program offer, eligibility, benefits, and requirements at any time without notice, including in specific states. This Program is limited to one per patient and may not be used with any other coupon, discount, prescription savings card, free trial, or other offer. This Program is not transferable. Patients may not seek payment for the value received through the Program from any health plan, patient assistance foundation, flexible spending account, or healthcare savings account. Void where prohibited by law, taxed, or otherwise restricted. The Program is not insurance. Program Administrator or its designee will have the right upon reasonable prior written notice, during normal business hours, and subject to applicable law, to audit compliance with this program.
Use and Disclosure of Information: Before the VIVITROL Co-pay Savings Card is activated, the patient will be asked to provide personal information that may include their name, date of birth, type of insurance, and contact information. This information is needed for the Program Administrator and its service providers to enroll the patient in the VIVITROL Co-pay Savings Program. Program Administrator will not share the patient’s personal information with anyone else except where legally permitted. Data shared with Alkermes by the Program Administrator will be aggregated and de-identified and may be used by Alkermes for its own internal business purposes and/or to improve or modify the Program. For more information, see Alkermes’ Privacy Policy at www.alkermes.com/privacy.
Any changes to these Terms and Conditions and/or the Program will be posted at www.vivitrolcopayterms.com.