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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 59011096201 | ZURNAI | nalmefene HCl | AUTO INJCT | 1.5 mg/0.5 mL | N | Y | N | |
| 12496000301 | OPVEE | nalmefene HCl | SPRAY | 2.7 mg/actuation | Y | Y | N | |
| 12496000302 | OPVEE | nalmefene HCl | SPRAY | 2.7 mg/actuation | Y | Y | N | |
| 59011096010 | NALMEFENE HCL | nalmefene HCl | VIAL | 2 mg/2 mL (1 mg/mL) | N | Y | N | |
| 63481035910 | NARCAN | naloxone HCl | AMPUL | 0.02 mg/mL | Y | Y | N | |
| 10019003968 | NALOXONE HCL | naloxone HCl | AMPUL | 0.4 mg/mL | Y | Y | N | |
| 60842000202 | NALOXONE HCL (STOCKPILE) | naloxone HCl | AUTO INJCT | 10 mg/0.4 mL | N | Y | N | |
| 00409178203 | NALOXONE HCL | naloxone HCl | CARTRIDGE | 0.4 mg/mL | Y | Y | N | |
| 00409178269 | NALOXONE HCL | naloxone HCl | CARTRIDGE | 0.4 mg/mL | Y | Y | N | |
| 00363214002 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 42291049301 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 42291049302 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 50090696300 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 72162237602 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 72162237604 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | N | N | |
| 00093216519 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 00093216568 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 00480347819 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 00480347868 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 45802057800 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 45802057884 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 46122081271 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 60219210401 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 60219210407 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 68001064545 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 69238210401 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 69238210407 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 70677128301 | NALOXONE HCL | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 69547035302 | NARCAN | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 69547062702 | NARCAN | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 76329366902 | REXTOVY | naloxone HCl | SPRAY | 4 mg/actuation | Y | Y | N | |
| 59467067901 | KLOXXADO | naloxone HCl | SPRAY | 8 mg/actuation | Y | Y | N | |
| 00074178221 | NALOXONE HCL | naloxone HCl | SYRINGE | 0.4 mg/mL | Y | Y | N | |
| 00641619301 | NALOXONE HCL | naloxone HCl | SYRINGE | 0.4 mg/mL | Y | Y | N | |
| 00641619310 | NALOXONE HCL | naloxone HCl | SYRINGE | 0.4 mg/mL | Y | Y | N | |
| 76045011401 | NALOXONE HCL | naloxone HCl | SYRINGE | 0.4 mg/mL | Y | Y | N | |
| 76045011410 | NALOXONE HCL | naloxone HCl | SYRINGE | 0.4 mg/mL | Y | Y | N | |
| 00641620501 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 00641620510 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 42023022401 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 43066014201 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 43066014210 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 43598075010 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 43598075011 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 43598075058 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 55150034501 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 55150034510 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 67457099202 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 76045011201 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 76045011220 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 76329146901 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 76329336901 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 76329346901 | NALOXONE HCL | naloxone HCl | SYRINGE | 1 mg/mL | Y | Y | N | |
| 72336007719 | LIFEMS NALOXONE | naloxone HCl | SYRINGEKIT | 2 mg/2 mL | Y | N | ||
| 00409121501 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 00409121521 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 00409121901 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 00409121941 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 00641613201 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 00641613225 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 36000030801 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 36000030810 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 36000031001 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 36000031002 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 55150032801 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 55150032810 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457029200 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457029202 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457029900 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457029910 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457064500 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457064502 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457098700 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 67457098710 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70069007101 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70069007110 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70069007201 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70069007210 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70756065810 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70756065825 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 70756065882 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 72572045001 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 72572045025 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 72603059001 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 72603059010 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N | |
| 72603059025 | NALOXONE HCL | naloxone HCl | VIAL | 0.4 mg/mL | Y | Y | N |