Submit number of DOSES 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 reversals reported using naloxone.
* Indicates required fields
Please provide dispensing information for each naloxone formulation in actual DOSES (not scripts/boxes)
NARCAN® (4MG/.1ML; NDC: 69547-353-02) – Please note Narcan® contains TWO doses per box.
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 box.
PLEASE NOTE: Evzio® is not currently authorized under the standing order
MULTI-STEP INTRANASAL (IN) (1MG/ML; NDC 76329-3369-01)