Opioid Reversal Agents

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
12496000301 OPVEE nalmefene HCl SPRAY 2.7 mg/actuation Y Y  
12496000302 OPVEE nalmefene HCl SPRAY 2.7 mg/actuation Y Y  
59011096010 NALMEFENE HCL nalmefene HCl VIAL 2 mg/2 mL (1 mg/mL) N Y  
63481035910 NARCAN naloxone HCl AMPUL 0.02 mg/mL Y Y  
10019003968 NALOXONE HCL naloxone HCl AMPUL 0.4 mg/mL Y Y  
60842000202 NALOXONE HCL (STOCKPILE) naloxone HCl AUTO INJCT 10 mg/0.4 mL N Y  
00409178203 NALOXONE HCL naloxone HCl CARTRIDGE 0.4 mg/mL Y Y  
00409178269 NALOXONE HCL naloxone HCl CARTRIDGE 0.4 mg/mL Y Y  
00363214002 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
42291049301 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
42291049302 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
50090696300 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
72162237602 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
72162237604 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y N  
00093216519 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
00093216568 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
00480347819 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
00480347868 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
00781717606 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
00781717612 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
45802057800 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
45802057884 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
45802081100 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
45802081184 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
46122081271 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
60219210401 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
60219210407 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
68001064545 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
69238210401 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
69238210407 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
70677128301 NALOXONE HCL naloxone HCl SPRAY 4 mg/actuation Y Y  
69547035302 NARCAN naloxone HCl SPRAY 4 mg/actuation Y Y  
69547062702 NARCAN naloxone HCl SPRAY 4 mg/actuation Y Y  
76329366902 REXTOVY naloxone HCl SPRAY 4 mg/actuation Y Y  
59467067901 KLOXXADO naloxone HCl SPRAY 8 mg/actuation Y Y  
00074178221 NALOXONE HCL naloxone HCl SYRINGE 0.4 mg/mL Y Y  
00641619301 NALOXONE HCL naloxone HCl SYRINGE 0.4 mg/mL Y Y  
00641619310 NALOXONE HCL naloxone HCl SYRINGE 0.4 mg/mL Y Y  
76045011401 NALOXONE HCL naloxone HCl SYRINGE 0.4 mg/mL Y Y  
76045011410 NALOXONE HCL naloxone HCl SYRINGE 0.4 mg/mL Y Y  
00641620501 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
00641620510 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
42023022401 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
43066014201 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y  
43066014210 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y  
43598075010 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
43598075011 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
43598075058 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
55150034501 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
55150034510 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
67457099202 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
76045011201 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
76045011220 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
76329146901 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
76329336901 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
76329346901 NALOXONE HCL naloxone HCl SYRINGE 1 mg/mL Y Y  
78670014002 ZIMHI naloxone HCl SYRINGE 5 mg/0.5 mL N Y  
78670014011 ZIMHI naloxone HCl SYRINGE 5 mg/0.5 mL N Y  
72336007719 LIFEMS NALOXONE naloxone HCl SYRINGEKIT 2 mg/2 mL Y  
00409121501 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
00409121521 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
00409121901 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
00409121941 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
00641613201 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
00641613225 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
36000030801 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
36000030810 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
36000031001 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
36000031002 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
55150032801 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
55150032810 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457029200 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457029202 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457029900 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457029910 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457064500 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457064502 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457098700 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
67457098710 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70069007101 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70069007110 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70069007201 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70069007210 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70756065810 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70756065825 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
70756065882 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
72572045001 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
72572045025 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
72603059001 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
72603059010 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
72603059025 NALOXONE HCL naloxone HCl VIAL 0.4 mg/mL Y Y  
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