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Alkermes CJV019569
Alkermes will make available samples of VIVITROL® (naltrexone for extended-release injectable suspension) 380 mg/vial, free
of charge, for use in a Criminal Justice System comprehensive reentry or specialized court program (“Program”) that includes the
followingcomponents:
* The treatment of medically appropriate adults as recommended by the FDA-approved product labeling.
* The medication is provided as a voluntary component of the Program and, in all instances, in combination with
psychosocial support, such as counseling.
+ Education on the risks, benefits, and appropriate use of the medication is provided to healthcare providers and patients
participating in the Program.
+ Acontinuity of care plan is developed.
« Program assessments are conducted in order to evaluate the Program’s overall effectiveness.
° Limited to one dose of VIVITROL per patient participating in such Program.
+ Each Criminal Justice System entity conducting the Program and the healthcare provider requesting and receiving the
VIVITROL samples (a) agrees not to sell, resell, trade, barter, return for credit, or seek third-party reimbursement for such
samples, and (b) agrees to ensure that any person using the samples received hereunder will comply with the restrictions
set forth in (a) above.
* VIVITROL will be handled, stored, and used in accordance with the package labeling for the product.
+ Alkermes, in its sole discretion, may discontinue or change product sampling at any time. Alkermes will provide
reasonable advance notice in the event of any such change or discontinuation. There is no obligation to continue the use of
VIVITROL for any patient who receives a V['VITROL sample through the Program.
Logistics:
+ Any Criminal Justice System entity conducting a Program that meets the above criteria and that wishes to request samples
must complete and sign a Criminal Justice System Certification and Sample Request Form (“CJSRF”) for VIVITROL,
which is set forth as Exhibit A, and fax or email a copy of such CJSRF to Alkermes using the cover page set forth as
ExhibitB.
* Upon receipt of these documents in a form satisfactory to Alkermes, Alkermes will ship sample(s) of VIVITROL to the
healthcare provider or licensed pharmacy listed in the CISRF. Please allow 3 to 5 business days for delivery of product
samples,
* The licensed healthcare provider or pharmacy (or his or her designee) must sign and return an Acknowledgement of
Content form to acknowledge receipt of the requested sample shipment.
Page 1 of 3
Please see accompanying Prescribing Information
(Alkermes CJV019569
Alkermes Representative Name:
Stacey Graninger
EXHIBITA
Criminal Justice System Certification and Sample Request Form(“CISRF”) for VIVITROL®
n nor ri
{naltrexone for extended-release injectable suspension) Samples
Certification
By signing this CISRF for VIVITROL samples, the Criminal Justice System entity hereby certifies that it is conducting a comprehensive reentry or
specialized court program (“Program”) that includes the following components:
+ The treatment of medically appropriate adults as recommended by the FDA-approved product labeling;
* The medication is provided as a voluntary component of the Program and, in all instances, in combination with psychosocial support,
such as counseling:
+ Education is provided with respect to the risks, benefits and appropriate use of the medication to healthcare providers and patients
participating in the Program;
+ Acontinuity of care plan is developed;
+ Program assessments are conducted in order to evaluate the Program’s overall effectiveness;
» Limited to one dose of VIVITROL per client participating in the Program;
* VIVITROL will be handled, stored and used in accordance with the package labeling for the product.
The Criminal Justice System and the licensed healthcare provider (signatories hereto) certify that (i) the samples of VIVITROL (manufactured by
Alkermes) received are for the medical needs of patients; (ii) they will not sell, resell, trade, barter, return for credit or seek third party reimbursement
for the product samples received; (iii) the healthcare provider listed below is validly licensed and eligible to request and receive product samples; (iv)
the pharmacy designated below, if any, is validly licensed and eligible to receive product samples; and (v) all product samples requested herein will
be used in the Program described above. Alkermes, in its sole discretion, may discontinue or change product sampling at any time. There is no
obligation to continue the use of VIVITROL for any patient receiving a VIVITROL sample.
Request for Product
The licensed healthcare provider listed below hereby requests_10__units* of VIVITROL 380 mg/vial (NDC# 65757-301-01) for use in the
Program, and requests that such samples be sent to the shipping address listed below.
In Witness WHEREOF, the Criminal Justice System entity and the licensed healthcare provider have each executed and delivered this certification by
duly authorized representatives as of the date listed below.
LICENSED HEALTHCARE PROVIDER REQUESTING SAMPLES
Provider Name (Print Full Name)___ Victor Gan
Provider Address: 3250 W Lower Buckeye City: Phoenix State: AZ Zip Code: 86009
State License Number: / LK 4 Professional Designation: In ))
Provider's Signature: AS id Date: 3/17/23
CRIMINAL JUSTICE SYSTEM ENTITY
Name of Criminal Justice System Entity: Maricopa County Correctional Health Services
Criminal Justice System Entity’s Address: 3250 W Lower Buckey Rd
City: Phoenix State : % Zip Code: 85008
Name of Entity’s Authorized aro Josie Camacho Title, Medieation Administration
Representative’s Signature: mado Date: 3/17/23
Shipping Address**
. Maricopa County Correctioanal Health Services
Name of Healthcare Entity: i y
. Victor Gan 602) 876-7138
Attention: Phone: ©)
3250 W Lower Buckeye Rd
Phoenix AZ _ 85009
City State Zip
* May be subject to quantity limitations.
** Samples may only be shipped to the requesting healthcare provider or Criminal Justice System pharmacy. All
samples are fulfilled by Aliermes’ authorized distributor of record (The Hibbert Group).
Page 2 of 3
Please see accompanying Prescribing Information
(Alkeri mes CJV019569
EXHIBITB
Request for Shipment of ViVITROL® (naltrexone for extended-release injectable suspension) Product Samples
From: Stacey Graninger
To: Alkermes, Inc,
Delivery Method: Fax to (609) 222-6290 or
Emailto AlkermesSRF@Hibbertgroup.com
In Re: Alkermes, Inc. Criminal Justice Sampling
Attention: Alkermes Sample Manager
The Criminal Justice System entity and the licensed healthcare provider identified on the attached Criminal Justice
System Certification and Samples Request Form (the “CJSRF”) hereby request shipment of samples of VIVITROL
in the amount, and to the address, listed on the attached CISRF.
Upon receipt of this document and the attached CJSRF, please proceed to ship product sample(s) to the shipping
address specified thereon.
Attachment: CISRF
ALKERMES and VIVITROL are registered trademarks of Alkermes, Inc.
©2020 Alkermes, Inc. All Rights Reserved. VIV-005691
www. vivitrolej.com
Page 3 of 3
Please see accompanying Prescribing Information