Narcan (Naloxone) Request Form

Last Name

First Name

Date of Birth

Email Address

Phone Number

Address

City/Town

State

Zip/Postal Code

Pharmacy Prescription Information

Card ID Number

Group Number

Plan Name

Please allow two business days for processing before coming to the pharmacy for pick up.

Cell phone number, if you would like to receive a text message when your request is ready for pickup:

Available Kits: Narcan (naloxone) single step kit will be provided and will include a patient information pamphlet with overdose prevention information and step-by-step instructions for overdose response and Narcan (naloxone) administration. Each Narcan (naloxone) single-step nasal spray kit includes a two-pack of Narcan (naloxone) 4mg (single-step) nasal spray.

Training: A training video can be found here. In addition, a printable guide can be found here.

Fill Prescriptions at BMC Pharmacies

Save up to 75 percent on prescription copays (covered employees and family members) by filling at BMC pharmacies

Yawkey
Shapiro
DOB
Crosstown
Cornerstone Health Solutions

BMC Pharmacies

All Other Pharmacies

30-day supply

$5/$10/$20

Specialty: $0

$20/$40/$80

Specialty: 20% of cost, up to $250

90-day supply

$10/$20/$60

Specialty: $0

$40/$80/$240

Specialty: 20% of cost, up to $750

Pharmacy Concierge Program

The BMC Concierge Program offers personal office delivery, home delivery, or pick up at one of our pharmacies to all employees. Submit the Concierge Enrollment Form to take advantage of these copay benefits.

Email DG-EmployeePharmacyServices@bmc.org for more information.

Available Kits: Narcan (naloxone) single-step kit will be provided and will include a patient information pamphlet with overdose prevention information and step-by-step instructions for overdose response and Narcan (naloxone) administration. Each Narcan (naloxone) single step nasal spray kit includes a two pack of Narcan 4mg (single step) nasal spray.

Training: Training videos are available here. Please click "download" on the right side of the page to download the video and guide on how to use naloxone.

Click here to learn more about ordering COVID kits, Narcan kits, OTC medications, the BMC pharmacy app, and much more.