Limited Coverage Drugs - Naltrexone

 Generic Name



 50 mg 




 Special Authority Criteria

 Approval Period

For the treatment of alcohol use disorder AND in combination with behavioural
intervention therapy (e.g., psychosocial counselling) as necessary.

  1 year

Practitioner Exemptions

  • PharmaCare coverage will be provided only for a patient who meets the Limited Coverage criteria, and whose prescription is written by a prescriber who has entered into a Collaborative Prescribing Agreement.
  • Due to the individual nature of each Collaborative Prescribing Agreement, the Agreement must be signed by the prescriber and not his/her delegate.

Special Notes

  • The above criteria is applicable for all PharmaCare coverage plans, including the Psychiatric Medications Plan (Plan G).

Special Authority Request Forms

  • Not applicable.