GETTING YOUR PATIENTS STARTED ON VIVITROL

1 your office can order VIVITROL directly from a distributor or through a pharmacy (specialty or other). GETTING your PATIENTS STARTED ON VIVITROLThis brochure will assist with:Specialty pharmacy processBuy-and-bill processVIVITROL Co-pay Savings ProgramPlease see Important Safety Information on page 9. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your 1: Order directly from a specialty pharmacyIf you re ordering VIVITROL directly from a specialty pharmacy, fax ALL of the following documents to the selected pharmacy: Copy of the signed VIVITROL prescription Prior Authorization Form (if applicable) Photocopy of the front and back of the patient s insurance card (enlarged to ensure legibility) Printed co-pay card* (available at )Option 2: Work with a dedicated case managerYou can also work directly with a dedicated case manager for assistance in fulfilling VIVITROL prescriptions.

2 Fax ALL of the following documents to Vivitrol2gether Support Services at 1-877-329-8484: Vivitrol2gether Support Services Enrollment Form (an editable PDF version of the Vivitrol2gether Support Services Patient Enrollment Form can be downloaded at ) Photocopy of the front and back of the patient s insurance card (enlarged to ensure legibility) Prior Authorization Form (if applicable)Vivitrol2gether Support Services is a resource designed to help PATIENTS with: Reimbursement coverage verification Submission of VIVITROL prescriptions to a pharmacy (specialty or other) Submission of VIVITROL co-pay assistance for eligible PATIENTS * Patient transition servicesCRITICAL Fax the PA form (if needed) and an enlarged photocopy of the patient s pharmacy and health insurance cards to the health insurer s toll-free fax number on the PA form.

3 Pharmacies and health insurers typically prefer that these items come directly from your office. Follow up within 24 hours to ensure the prescription is being processed. Remember to identify the date of the scheduled injection. If the specialty pharmacy cannot process the prescription for VIVITROL , consider enrolling your patient into Vivitrol2gether to receive pharmacy routing directly with Vivitrol2gether for assistance in fulfilling VIVITROL prescriptions. Our team is ready to support you and your PATIENTS . Call 1-800- VIVITROL (1-800-848-4876), 9am 8pm (EST) and visit to access a variety of helpful PHARMACY PROCESSORDERING VIVITROL ( naltrexone FOR extended - release injectable SUSPENSION)FROM A SPECIALTY PHARMACYWhen ordering VIVITROL , you can work directly with a pharmacy (specialty or other) or you can work with a Vivitrol2getherSM dedicated case manager.

4 With Vivitrol2gether, you choose the VIVITROL fulfillment features that work best to support your PATIENTS .*See page 8 for VIVITROL Co-pay Savings Program eligibility see Important Safety Information on page 9. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your PATIENTS . MEDICATION GUIDEPRESCRIBING INFORMATIONVITROLhRViss brocueeVITROLhiOs brihRoIroOcVITROLhiLs hbrLosVibROIhLVRisbROscVcVLORueSPECIALTY PHARMACY PROCESS3 SPECIALTY PHARMACY PROCESSTHE SPECIALTY PHARMACY PROCESS FLOWW hether you have elected to send the prescription directly to the pharmacy (specialty or other) or have chosen to go through Vivitrol2getherSM, there are certain tasks that the specialty pharmacy will perform once you or your staff have completed the relevant forms.

5 If specialty pharmacy is not contracted to fill prescriptions for a specific health insurer, the prescription is transferred to another VIVITROL ( naltrexone for extended - release injectable suspension) prescription Determine the specialty or other pharmacy options available based on the patient s health plan coverage Discuss the VIVITROL Co-pay Savings Program with the patient; eligible PATIENTS can sign up and provide the required information to the pharmacy Remind your PATIENTS to expect a call from the pharmacy and/or nurse coordinator to review important information about the first pharmacy order Insurance, Co-pay Savings and Prescription Verification Specialty or other pharmacy performs a benefit verification on behalf of the patient and confirms prescription verification and prior authorization with the health plan Co-pay savings are applied for eligible PATIENTS Patient authorizes paymentSchedule shipping and delivery Patient is contacted to schedule or confirm delivery date Patient is called about next steps and follow-upRx is filled and ready to ship Pharmacy contacts patient and provider s office to authorize shipment After patient authorization.

6 Pharmacy will contact your office to set up delivery Prescription is filled by pharmacy and shipped to your officeDelivery of VIVITROL Office receives VIVITROL Patient receives injection of VIVITROL your patient s follow-up appointment is scheduledFollow-up for next injection Schedule follow-up appointment for the next injectionSuggestions to help improve fill time Learn which pharmacies (specialty or other) work with your PATIENTS health plans Establish a relationship with the specialty pharmacy contact person and determine the best way for you to communicate ( , phone, email, or fax) Follow up regularly and be sure to communicate the required injection date of VIVITROL for each patient123456 Please see Important Safety Information on page 9. Also see Prescribing Information and Medication Guide.

7 Review the Medication Guide with your PATIENTS . MEDICATION GUIDEPRESCRIBING INFORMATIONBUY-AND-BILL PROCESSCO-PAY SAVINGS PROGRAMIMPORTANT SAFETY INFORMATION FOR VIVITROL SPECIALTY PHARMACY PROCESS4 VIVITROL Provider Pricing ProgramDirect-purchase discount is available to eligible* providers through Besse Medical and Smith Medical Partners, the Alkermes-preferred distribution pricing For eligible* providers available through Besse Medical and Smith Medical Partners Single- and multiple-carton contract pricing discount 10% to 18% off wholesale acquisition cost (WAC) based on quantity purchased extended payment terms of 75 days Accommodates reimbursement timingBUY-AND-BILL PROCESSORDERING VIVITROL ( naltrexone FOR extended - release injectable SUSPENSION)THROUGH BUY-AND-BILL * Contact Besse Medical or Smith Medical Partners regarding eligibility for program pricing.

8 Uninsured program pricing is not available through Smith Medical Partners. One unit contains 1 dose of 10 NDC 11 Strength (Package Size)Order QuantityDiscount Price (%)VIVITROL380-mg vial65757-300-0165757-0300-01380-mg vial1 to 4 units WAC 10%VIVITROL380-mg vial65757-300-0165757-0300-01380-mg vial5 to 24 units WAC 15%VIVITROL380-mg vial65757-300-0165757-0300-01380-mg vial25 or more units WAC 18%Please see Important Safety Information on page 9. Also see Prescribing Information and Medication Guide. Review the Medication Guide with your PATIENTS . MEDICATION GUIDEPRESCRIBING INFORMATIONSPECIALTY PHARMACY PROCESSCO-PAY SAVINGS PROGRAMIMPORTANT SAFETY INFORMATION FOR VIVITROL BUY-AND-BILL PROCESS5To get STARTED with VIVITROL Provider Pricing Program, set up an account with your chosen distribution partnerFor Besse Medical: Go to to access a Besse Business Application Applications can be completed online; downloaded, printed, and faxed to 1-888-375-0030.

9 Or scanned and emailed to Besse Medical retains sole discretion for opening an account and establishing credit limitsWhen your Besse Medical account is set up, you are ready to order VIVITROL Order online at Call 1-800-543-2111 to order by phone Fax your order to 1-800-543-8695 For Smith Medical Partners: Go to and click Get STARTED to become a customer Application can also be requested via email to or by calling 1-800-292-9653 Applications should be downloaded, printed and faxed to 630-227-9220; or scanned and emailed to Include Physician s State License and DEA Registration numbers with faxed or emailed application Smith Medical Partners retains sole discretion for opening an account and establishing credit limitsWhen your Smith Medical Partners account is set up, you are ready to order VIVITROL Order online at (registration required) Call 1-800-292-9653 to order by phone Fax your order to 630-227-9220 BUY-AND-BILL PROCESSORDERING VIVITROL ( naltrexone FOR extended - release injectable SUSPENSION)THROUGH BUY-AND-BILL (CONTINUED) VIVITROL is shipped overnight for next-day delivery so VIVITROL can be available when your PATIENTS need see Important Safety Information on page 9.

10 Also see Prescribing Information and Medication Guide. Review the Medication Guide with your PATIENTS . MEDICATION GUIDEPRESCRIBING INFORMATIONSPECIALTY PHARMACY PROCESSCO-PAY SAVINGS PROGRAMIMPORTANT SAFETY INFORMATION FOR VIVITROL BUY-AND-BILL PROCESS6 Reimbursement codes for VIVITROL ( naltrexone for extended - release injectable suspension)Coding decisions should be made by the healthcare provider based on an independent review of the patient s condition. Below is a list of codes you may find Diagnosis CodesClaims submitted for VIVITROL should include at least one (1) ICD-10-CM diagnosis code to indicate the patient s condition. Specific diagnosis codes should represent the condition as supported by the patient s medical record. The diagnosis codes listed below may apply for PATIENTS for whom VIVITROL may be PROCESSCODING AT A GLANCEVIVITROL CodingProfessional ServicesProfessional ClaimsNDC for VIVITROL1 HCPCS2 CPT3 ICD-10-CM Procedure4 Place of Service Codes565757-0300-01J2315963723E023GC1121 2255 naltrexone for extended - release injectable suspensionInjection, naltrexone , depot form, 1 mgTherapeutic, prophylactic, or diagnostic injection (specify material injected).