| |
Program Details
ALKERMES, INC.
Vivitrol2gether Support Services
Vivitrol
(naltrexone for extended-release injectable suspension)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-800-848-4876 |
Provider Phone: |
|
| Fax: |
1-877-329-8484 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have prescription coverage for medication needed.
Patient must meet program income criteria which is based on Federal Poverty Level.
Program offers co-payment assistance, reimbursement support, patient support, and patient assistance programs for eligible patients. |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Not Published
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
1 Dose
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 01/10/2025
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
Vivitrol2gether Enrollment Form
|
|
