Insurance Coverage for Naloxone

Research SummaryPublished Dec 19, 2023

Requires health insurance plans to provide coverage for at least one generic opioid antagonist and device approved to treat opioid overdose (e.g., naloxone) without prior authorization.

A panel of experts rated how they expect this type of policy to affect four outcomes: naloxone distribution through pharmacies, opioid use disorder (OUD) prevalence, rates of nonfatal opioid overdose, and opioid overdose mortality. Another panel of experts rated the policy on four implementation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
Naloxone Pharmacy Distribution
No
No
Yes
OUD Prevalence
No
Yes
No
Nonfatal Opioid Overdose
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect the policy to substantially increase pharmacy distribution because it addresses the significant barrier of out-of-pocket costs to individuals, but it would not impact naloxone distribution sufficiently to impact fatal overdoses.
  • Experts feel the public supports shifting cost burdens to the insurance companies covering the medication.
  • Experts believe the policy is feasible because states and communities could easily implement it.
  • Experts rated the policy as affordable: Generic naloxone is relatively inexpensive, and the policy is cost-effective.
  • Experts believe the policy would reduce inequities among those who are insured and prescribed naloxone by reducing bureaucratic red tape with insurers.

Outcome Summaries

Naloxone Pharmacy Distribution

Amount of naloxone dispensed through retail pharmacies (e.g., chain pharmacy stores, independent community pharmacies).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Could lower the financial threshold to obtain naloxone, thereby increasing distribution. "Insurance coverage is the biggest barrier right now, if it is taken care of, naloxone sales would increase"
Little-to-no Depends on the nature of coverage (e.g., co-pays), type(s) of naloxone covered, and the size of the (un)insured population. "Why limit this to generic? Everyone wants Narcan or Evzio, not a vial and syringe. Brands I would expect to have a difference. Generic, not really"
Harmful N/A N/A

Opioid Use Disorder Prevalence

Percentage of the general population with a pattern of opioid use leading to clinically and functionally significant impairment, health problems, or failure to meet major responsibilities.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking insurance coverage and OUD prevalence. "Not target of insurance for naloxone"
Harmful N/A N/A

Nonfatal Opioid Overdose

Per capita rates of nonfatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial N/A N/A
Little-to-no
(selected)
 No credible mechanism linking insurance coverage and nonfatal overdoses. "I don't think naloxone access has much if any impact on the prevalence of nonfatal opioid overdose"
Harmful Potential for revival from overdose could (1) have a small, indirect, and mechanistic impact on nonfatal overdoses due to increased survivorship and (2) lead to continued opioid misuse. "People who want naloxone but can't afford it likely fall into high-risk categories, with greater access, more saves"

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increase in naloxone pharmacy distribution will yield meaningful decreases in fatal overdoses. "Forcing insurance companies to cover Naloxone would mean that the cost barrier would be greatly reduced, and more folks having less barriers to getting Naloxone would lead to more nonfatal overdoses and less fatal overdoses"
Little-to-no
(selected)
 Does not impact naloxone distribution sufficiently to impact fatal overdoses. "Seems unlikely to have substantial impact"
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 General public supports shifting cost burdens to insurance companies covering the medication. "Public increasingly supports insurers covering more medications"
Moderate Concerns about stigma around the use of naloxone. "I still know health insurers that don't cover contraceptives, whether that's a financial decision or a 'moral' one. And sex generally is much more acceptable than the stigma we place on individuals suffering from an opioid addiction"
Low N/A N/A

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 States and communities could easily implement the policy because the cost burden is on the insurers. "The burden is on the insurer, so this should be relatively simple to implement for the state/community"
Moderate Concerns about potential pushback from insurers during implementation. "Many health insurance plans would need to comply, so order would need to be federally mandated and enforced"
Low N/A N/A

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Generic naloxone is relatively inexpensive so the policy would be cost-effective. "So long as the generics are negotiated in the state formulary, the rates for these drugs should be minimal"
Moderate Concerns about the cost of naloxone and legal actions from insurers. "Creating the policy may require a lobbying battle with insurers"
Low N/A N/A

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Reduces inequities among those who are insured and prescribed naloxone by reducing bureaucratic red tape with insurers. "This policy helps address inequities in prescribed naloxone due to income and insurance type"
Moderate Maintains status quo for those without insurance. "It assumes insurance coverage, which still leaves out the most vulnerable populations"
Low Concerns about lack of reach to those without insurance, size of co-pays for those who do have insurance, and coverage of only one type of naloxone. "For serious public health concerns, the insurance-based approach seems insufficient because of the irregularities of insurance, and the reality that many people lack it, especially people who are personally at risk or who live in communities that are at greatest risk. So insurance-based mechanisms likely would be inequitable and fall short in saving lives"
Cover: Insurance Coverage for Naloxone

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Insurance Coverage for Naloxone. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-14.html.
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