Narcan — CareFirst (Caremark)

Emergency treatment of known or suspected opioid overdose as manifested by respiratory and/or central nervous system depression

Initial criteria

Authorization may be granted when the requested drug is being prescribed in the event that emergency treatment of opioid overdose may be needed when the following criterion is met:
The patient requires MORE than 2 nasal spray cartons (4 nasal sprays) OR 2 pre-filled syringe cartons (4 pre-filled syringes) OR 4 auto-injector cartons (4 auto-injectors) of the requested drug per month due to ANY of the following:
• The type of opioid that the patient is taking (e.g., buprenorphine, pentazocine, long-acting/extended-release opioids)
• The patient is living in an area that has a longer wait time for emergency medical assistance
• The patient had an overdose episode that required the use of the requested drug

6 months