Limited Coverage Drugs - Naltrexone

Generic Name / Strength / Form
naltrexone
Criteria Approval Period

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

3 months

Practitioner Exemptions

  • PharmaCare coverage will only be provided 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 (PDF 53K).
  • 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

  • Criteria applicable for all plans including Plan G.

Special Authority Forms

Not applicable.