Naloxone Formulary Overview
Medicare Part D and commercial insurers vary in their coverages and copays. In general:
- Most cover generic naloxone (IM or generic intranasal)
- More likely to cover Nasal Narcan than Evzio
- Evzio, if covered, is quite costly and may have high copays
- naloxone ampule/syringe/vial (generic for Narcan®)
- Narcan® Nasal Spray
NOTE: Patient must try and fail two preferred products to get a non-preferred product; or have a unique clinical circumstance documented on the Standard Drug Request Form.
Medicaid copay of $3 applies for a naloxone rescue kit. NOTE: the generic intranasal naloxone requires a “kit” costing ~$12 which is not covered by Medicaid.
Note regarding Medicaid copays: An eligible Medicaid beneficiary, who receives prescribed drugs, is required to make a co-payment of $3.00 for each prescription received unless they are exempt (NC Medicaid Outpatient Pharmacy Policy 5.5.1). A provider may not deny services to any Medicaid beneficiary because of the individual’s inability to pay a deductible, coinsurance or co-payment amount. A provider may not willfully discount copays for a Medicaid beneficiary, and an individual’s inability to pay does not eliminate his or her liability for the cost sharing charge.
Note: pregnant women on Medicaid should not pay copays on medication. The co-payment exemption is made automatically by the claims processing system for an eligible beneficiary. In the event that the system does not override the copay, the pharmacy may use any of the ICD-10-CM codes listed in Attachment J (see page 72) to indicate pregnancy. A “4” in the Prior Authorization Type Code or a “2” in the pregnancy indicator field on a point-of-sale (POS) claim also indicates an exemption from the co-payment deduction for pregnancy.
Where Can I Get Naloxone?
Visit NaloxoneSaves.org to learn more about where you can get Naloxone.
Naloxone from Health Departments
Access a list of NC Health Departments with standing order protocols.
As of May 2017, of the 34 health departments statewide that offer naloxone locally, these include:
- Wake County Human Services Pharmacy
NC Harm Reduction Coalition
Since the Overdose Prevention Project (OPP) became operational August 1, 2013, NCHRC has dispensed over 101,000 free overdose rescue kits that include naloxone (as of January 1, 2019) and have received 13,394 confirmed reports that the life-saving medication was administered successfully by lay individuals. Currently, the OPP has over 130 volunteer contractors who dispense the overdose rescue kits throughout the state.
NCHRC would like to distribute free overdose rescue kits to individuals who can be described as:
- Active IV drug user
- On medication-assisted treatment (MAT)
- Formerly incarcerated with a history of opiate use
- Engaged in sex work
- Identifying as transgender
To reach NCHRC regarding a person at risk of experiencing or witnessing a drug overdose, visit http://www.nchrc.org/programs-and-services/ or call/text (910) 685-5596 or email Jesse Bennett at [email protected] to get an overdose rescue kit.
Syringe Exchange Sites
Naloxone is also available at the various syringe exchange sites around the state. Find your local syringe exchange site.
Naloxone is free from local MAT programs
Programs receive Nasal Narcan. NC Harm Reduction comes and distributes IM naloxone at the following Wake/Durham/Johnston/Cumberland sites (list of statewide sites).
- Metro-Durham Treatment Center
- CRC Health-Fayetteville
- Johnston Recovery Services
- Raleigh Methadone Treatment Center-Raleigh )
- Southlight Opiate Treatment-Raleigh
Available Naloxone Products
NOTE: A naloxone rescue kit contains two naloxone doses.
Generic IM Naloxone – least expensive version
- Formulation with most lay person experience (past 20 years)
- NC Harm Reduction has been distributing IM naloxone in NC since 2013
- Needle used is NOT desirable for IVDU (too large)
- If the patient has no insurance, free overdose rescue kits are available to the following groups of people; active IV drug users, people on medication-assisted treatment, people who are formerly incarcerated with a history of opiate use, people engaged in sex work or people who identify as transgender. To receive a free kit, contact NC Harm Reduction Coalition (NCHRC)
Branded – Nasal Narcan 4mg (two nasal devices per kit).
- Easiest to use – no assembly required, no priming should be done
- AWP ~ $125
- Public Interest Pricing $75/kit – direct purchase from the manufacturer available to all Qualified Group Purchasers, such as first responders (EMS, Fire Department, Police), community organizations and Departments of Health – https://www.narcandirect.com/
- Nasal bioavailability is 45%
GENERIC – Intranasal Naloxone “Project Lazarus Kits”
- “Bridge” product until Nasal Narcan approved in November 2015
- Off label use of luer-lock syringe product with a nasal atomizer
- Requires assembly –complicated in overdose emergency situation
- Kits (everything but naloxone) no longer provided by CCNC but can be purchased via Project Lazarus’ website
- Cost of naloxone and kit may be comparable to branded intranasal product pubic interest pricing
NC DHHS Website – http://www.NaloxoneSaves.org/
Statewide standing order, patient education resources, referrals, notify the state
Prescribe to Prevent – Best overall site – patient education including videos http://prescribetoprevent.org/pharmacists/pharmacy-basics/
Calculator MME (milligrams of morphine equivalents) http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm
College of Psychiatric and Neurologic Pharmacists
- Naloxone Guideline for Pharmacists – not specific for NC – https://cpnp.org/_sdocs/guideline/naloxone/naloxone-access.pdf
- Opioid Use Disorders – Interventions for Community Pharmacists https://cpnp.org/_sdocs/guideline/naloxone/naloxone-access.pdf
NC Harm Reduction Coalition – http://www.nchrc.org/programs-and-services/
Provide free naloxone to eligible persons – case workers meets patient – http://www.nchrc.org/programs-and-services/ost/ – works w/MAT program to give free NLX
NC Standing Order for Naloxone
Key points about the naloxone standing order:
- A standing order is a medical order that authorizes the dispensing of a medication, like naloxone, to any person who meets criteria designated by the prescriber.
- North Carolina’s standing order, signed by North Carolina’s State Health Director, authorizes any pharmacist practicing in the state of North Carolina and licensed by the North Carolina Board of Pharmacy to dispense naloxone to any person who meets certain criteria.
- No specific training or certification is required of the pharmacist to participate in the standing order.
- Evzio is not included in the standing order.
Patient Education Pointers
KEY POINTS TO CONSIDER
- Majority of opioid “overdose” in the US occurs with Rx opioids and is UNINTENTIONAL
- AVOID use of word “overdose” or “addict” or “narcotic” with patient as the term may not be relatable to at-risk LEGAL opioid users – CONSIDER using the terms “adverse reaction stopping breathing” from “prescription pain medicine”
- At-risk patients (see standing order for complete list) include those with:
- COPD, asthma, kidney or liver or heart disease, HIV
- “High” opioid doses – >50 morphine milligram equivalents (MME) http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm
- Combinations with other CNS depressants (alcohol, sedative/hypnotics, muscle relaxants and especially benzodiazepines)
- Benzodiazepine and opioid combinations have 10X the overdose DEATH risk compared to opioids alone (August 2016 black box warning)
- Methadone – twice as risky as other opioids
- Recent release from hospital, jail or detox or abstinence programs – loss of tolerance is a key education point
- Overdosed in past – >90% seen in ED for opioid overdose will continue on opioids and ~50% will overdose again within two years
- Use the CSRS to register yourself (MD/DO, RPh) or to assign delegates who may check on your behalf.
INITIATE THE CONVERSATION – Conversation starters to use INSTEAD of “overdose”
- “I want to improve the safety of these dangerous/risky medications that can turn off the brain’s breathing center
- “Just in case,” like a fire extinguisher – naloxone
- Safety around pets and children (experimenting teens) who have accidentally died
SAFE STORAGE AND DISPOSAL of unused opioid doses is crucial. Most illicit opioid users started out by borrowing or stealing Rx opioids from friends/family (legal and legitimate users). Four out of five heroin users started out with Rx opioids. Society needs fewer opioids out there. To find the closest drug disposal location near you, visit https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1
THIRD PARTY PRESCRIBING – see FAQs
IT IS LEGAL AND ETHICAL for pharmacies to sell insulin syringes – NO QUESTIONS asked. Prevent transmission of Hep C and HIV. Syringes sales to IVDU does NOT encourage the habit. Reference http://www.ncbop.org/faqs/FAQsNonPrescriptionSyringeSalesNC.pdf.
MENTAL HEALTH OR SUBSTANCE USE CRISIS REFERRAL – Reference http://crisissolutionsnc.org/.
Referral for Treatment of SUDs
Visit NaloxoneSaves.org and navigate to General Information, then Local Resources, then Referral for Treatment:
- To find mental health and substance abuse services in your community, visit this North Carolina providers directory or the Substance Abuse and Mental Health Services Administration Directory.
- To find crisis services in your community, visit Crisis Solutions NC.
- To access 24/7, confidential support for those in suicidal crisis, please call the National Suicide Prevention Lifeline at (800) 273-TALK (8255).
- Carolinas Poison Center, to access 24/7 poison help line please call (800) 222-1222.