Limited Coverage Drugs - Naltrexone

 Generic Name

 naltrexone

 Strength

 50 mg 

 Form

 tablet

 

 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.