Most Medicaid plans cover naloxone but barriers still exist

A new study found that almost all plans in 40 states and Washington, DC covered at least one form of the opioid overdose reversal drug naloxone, although certain restrictions and quantity limits may still prevent people from accessing this life-saving drug.

In 2023, the US Food and Drug Administration approved the overdose reversal drug naloxone, commonly known as Narcan, for over-the counter (OTC) use. While hailed as a public health success for increasing access to this life-saving drug, this OTC option remains out of reach for people who cannot afford the $45 average price tag for a two-dose box.

Medicaid recipients are a low-income population that disproportionately experiences opioid overdoses, so access to low- or no-cost naloxone through insurance can help to save lives. A new study led by Boston University School of Public Health (BUSPH) investigated Medicaid managed care plan coverage of naloxone across the nation.

Published in JAMA Network Open, the study found that almost all Medicaid managed care plans (MCPs) cover at least one of the four formulations of naloxone. Eighty percent of Medicaid recipients, which include more than 70 million people, are enrolled in these plans. The study is the first to assess naloxone coverage within MCPs.

These findings are important because over-the-counter naloxone can still be very expensive and insurance coverage can reduce the cost barrier to accessing this drug. The overdose death rate among Medicaid beneficiaries is twice as high as the overdose rate among the general US population. Low-barrier and low-cost naloxone could help get this essential medication into the hands of people who are at high risk for overdose death."

Sage Feltus, study lead and corresponding author, research associate in the Department of Health Law, Policy & Management (HLPM) at BUSPH

The study's senior author is Dr. Maureen Stewart, research associate professor in HLPM at BUSPH, and coauthors include Dr. Jeffrey Bratberg, clinical professor at The University of Rhode Island College of Pharmacy, and Sophia Balkovski, a doctoral trainee at the Heller School for Social Policy and Management at Brandeis University.

After rising sharply during the COVID-19 pandemic, drug overdose deaths involving opioids declined to 83,140 in 2023, followed by a significant drop to 54,743 deaths in 2024, according to provisional data from the Centers for Disease Control and Prevention. Naloxone, which is considered the cornerstone of the harm-reduction approach to the nation's opioid overdose emergency, can quickly reverse the effects of opioids such as heroin, oxycodone, and fentanyl. Experts have long sought to increase awareness of and access to this medication to safely and effectively reduce deaths from opioid use.

For the study, the researchers reviewed the preferred drug lists from 264 MCPs that covered 65.3 million Medicaid recipients in 40 states and Washington, DC. Insurance companies and states can use these preferred drug lists to negotiate rebates with drug manufacturers. The team examined MCP reported coverage and management of all available formulations of naloxone: brand and generic 4-mg nasal sprays; a generic injectable; and a newer, high-dose, brand nasal spray in 8 mg. They also reviewed publicly available data on state-level opioid overdose deaths.

While quantity limits and other restrictions varied by plan, 94 percent of plans reported covering at least one generic injectable or 4-mg generic/brand versions of the nasal spray of naloxone, and 91 percent covered the 4-mg generic or brand nasal spray and injectable formulations. The generic versions of the drug were the most common forms listed on PDLs. Over half of plans (covering 42 million Medicaid recipients) had state-defined PDLs, and these plans were less likely to report covering the generic injectable naloxone.

Notably, three states with no MCPs covering at least one form of naloxone-Ohio, Kentucky, and Tennessee-had high opioid overdose rates, although the researchers caution that more data is needed to understand the causes of these high death rates. The findings did show that MCPs in states with low overdose rates were more likely to cover all forms of naloxone and less likely to impose quantity limits. Further research should identify how Medicaid coverage of naloxone contributes to recipients' health, and MCPs should work to ease restrictions that make it difficult for people to actually receive this medication.

"Reporting coverage is a critical first step," Feltus says. "Removing prior authorization requirements may ease administrative burden for providers prescribing naloxone. We don't know as much about the impact of quantity limits on naloxone but this restriction could present a barrier for Medicaid recipients who may need more than the allowed amount per month or year."

States can take action to increase access to naloxone, she adds. 

"States can require that MCPs cover all forms of naloxone by including all formulations on a uniform preferred drug list, or in contract requirements with MCPs."