COVERED USES:

FDA Approved Indications: Maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. Treatment with Campral® should be part of a comprehensive management program that includes psychosocial support.

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Both of the following must be met for initial authorization:

1. Documentation that the member is part of an alcohol recovery treatment program, such as Alcoholics Anonymous, or community-based rehabilitation program, AND
2. Member is abstaining from alcohol

For Reauthorization:

1. Member is abstaining from alcohol

Requests for treatment durations beyond twelve months will require medical and evidence-based rationale for extended use.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization will be for up to 2 months. Reauthorization will be for 2-12 months.