Vivitrol2Gether Patient Enrollment Form
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Web an enrollment form for offices that wish to work with a vivitrol2gether ® dedicated case manager to send prescriptions to pharmacies on behalf of their patients. Fill vivitrol enrollment form, edit online. Web link to vivitrol2gether ® enrollment form on previous page. In addition, it provides information on vivitrol2gether℠, including assistance with vivitrol acquisition. Patient will transition to provider.
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Another option if vivitrol is covered through the medical benefit is for the healthcare provider to buy units of vivitrol from a specialty distributor and bill the patient’s insurance directly when it is administered. If you elect to work directly over pharmacies, were provide the resources you needing, with vivitrol my members available to answer your questions Transition of care coordination patient needs vivitrol by (date) / preferred pharmacy (optional) / phone # special shipping instructions please select one patient will receive future injections at this site. Patient diagnosis —(a list of possible codes can be found on page 5, section 15)
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