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.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| nalmefene HCl | OPVEE | SPRAY | Y | N | ||
| naloxone HCl | NALOXONE HCL | AMPUL | Y | N | ||
| naloxone HCl | NARCAN | AMPUL | Y | N | ||
| naloxone HCl | NALOXONE HCL | CARTRIDGE | Y | N | ||
| naloxone HCl | NALOXONE HCL | SPRAY | Y | N | ||
| naloxone HCl | REXTOVY | SPRAY | Y | N | ||
| naloxone HCl | NARCAN | SPRAY | Y | N | ||
| naloxone HCl | KLOXXADO | SPRAY | Y | N | ||
| naloxone HCl | NALOXONE HCL | SPRAY | Y | N | ||
| naloxone HCl | NALOXONE HCL | SYRINGE | Y | N | ||
| naloxone HCl | NALOXONE HCL | VIAL | Y | N | ||
| nalmefene HCl | ZURNAI | AUTO INJCT | N | N | ||
| nalmefene HCl | NALMEFENE HCL | VIAL | N | N | ||
| naloxone HCl | NALOXONE HCL (STOCKPILE) | AUTO INJCT | N | N | ||
| naloxone HCl | LIFEMS NALOXONE | SYRINGEKIT | N |