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To submit a medical co-pay claim for VIVITROL® (naltrexone for extended-release injected suspension) you need:

  • Patient’s co-pay card information
  • Explanation of Benefits (EOB) or remittance form for insured patients
  • Specific information regarding the patient, prescriber, date of therapy, administration, etc.
  • Patient’s itemized cash receipt (required for self-pay patients)
  • Denial of Coverage (required for Insured, not covered self-pay patients)

Please note:
*Eligibility for Alkermes-Sponsored Co-pay Savings. This offer is only available to patients 18 years or older, with a prescription consistent with the Prescribing Information and the patient is not 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 or Medicare Advantage plans; Medicaid, including Medicaid Managed Care and Alternative Benefit Plans under the Affordable Care Act; Medigap; VA; DOD; TRICARE; or a residential correctional program.
Additional Terms of Use: This offer is not conditioned on any past, present, or future purchase, including refills. Alkermes reserves the right to rescind, revoke, or amend this offer, program eligibility, and requirements at any time without notice. This offer is limited to one per patient, may not be used with any other offer, is not transferable and may not be sold, purchased or traded, or offered for sale, purchase or trade. Void where prohibited by law. 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.