Submit number of kits of each naloxone formulation/product dispensed to DOHMH at the end of the month following the close of each quarter.
Please submit a Reversal Reporting Form for any naloxone administrations reported.
* Indicates required fields
Please provide dispensing information for each naloxone formulation in kits (kit = 2 doses)
Narcan® (4MG/.1ML; NDC: 69547-353-02) – Please note Narcan® contains TWO doses per KIT.
Intramuscular (IM) (0.4MG/ML; NDC 00409-1215-01 OR NDC 67457-0292-02)
Evzio® (2 MG/ML; NDC 60842-051-01) – Please note Evzio® contains TWO doses per KIT.
PLEASE NOTE: Evzio® is not currently authorized under the standing order
MULTI-STEP Intranasal (IN) (1MG/ML; NDC 76329-3369-01)