Naloxone Formulary Overview
NC DHHS Syringe and Naloxone Access webpage
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
NC Medicaid Preferred Drug List (PDL) status
Preferred:
- 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 (for Medicaid Direct); for an individual’s specific NC Medicaid managed care organization standard drug request form, please visit that organization’s website.
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 9, Section 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 75) 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
As of October 2021, 37 health departments statewide indicated on the Naloxone Saves website that they offer naloxone, and these include the following Alliance catchment area counties:
- Durham
- Wake County Human Services Pharmacy
- Johnston
- Cumberland
- Orange
NC Harm Reduction Coalition
Since the Overdose Prevention Project (OPP) became operational August 1, 2013, NCHRC has dispensed over 80,000 free community overdose kits that include naloxone (as of 8/2/2018) and have received 11,583 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.
- Medications for opioid use disorder (MOUD).
- 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 the NCHRC website, call/text -910-685-5596, or email Jesse Bennett at [email protected].
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 MOUD programs
Programs receive nasal Narcan. NC Harm Reduction distributes IM naloxone at the following Wake/Durham/Johnston/Cumberland sites (list of statewide sites).
- Durham: BAART, Metro-Durham Treatment Center.
- Cumberland: Fayetteville: CRC Health-Fayetteville, Metro-Fayetteville.
- Johnston: Johnston Recovery Services.
- Mecklenburg: Charlotte Treatment Center, Queen City Treatment Center-Charlotte.
- Wake: Raleigh Methadone Treatment Center, Southlight.
Available Naloxone Products
NOTE: A naloxone rescue kit contains two naloxone doses.
Injectable Naloxone
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).
Intranasal Naloxone
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%
Kloxxado 8mg (two nasal devices per kit). Just released; information will be updated shortly.
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 which is complicated in overdose emergency situation.
- Kits (everything but naloxone) are 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.
Naloxone Information
NC DHHS “Naloxone Saves” website. Statewide standing order, patient education resources, referrals, notify the state.
Prescribe to Prevent. Best overall site. Includes patient education including videos.
Morphine Milligram Equivalents (MME) Calculator.
College of Psychiatric and Neurologic Pharmacists
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 the use of the 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).
- 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. Find the closest drug disposal location near you.
Third-party prescribing: Third party prescribing/dispensing permits the prescription and dispensing of naloxone to a person other than the person at risk of overdose. The 2013 Naloxone Access Law passed in North Carolina under G.S. 90-12.7 (formerly codified as G.S. 90-106.2), a health care provider may write a standing order to allow the dispensing of naloxone to people at risk for an overdose and to those in a position to help others at risk of an overdose, known as third-party prescribing. The statute provides criminal and civil liability protection to health care providers who prescribe naloxone and to those who administer naloxone to persons experiencing an overdose.
It is legal and ethical for pharmacies to sell insulin syringes, no questions asked. Prevent transmission of Hep C and HIV. Syringe sales to IVDU does NOT encourage the habit. Reference http://www.ncbop.org/faqs/FAQsNonPrescriptionSyringeSalesNC.pdf.
Mental health or substance use crisis referral: Crisis Solutions North Carolina.
Referral for Treatment of SUDs
- MorePowerfulNC has a comprehensive listing of treatment options.
- 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.
