Quarterly Pharmacy Naloxone Dispensing Report

For Naloxone Non-Patient Specific Prescription and Dispensing Protocol

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

Reporting period*

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)

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