Medicaid Managed Care Plans Increasingly Cover Naloxone, Yet Access Challenges Persist

Recent research indicates that the majority of Medicaid managed care plans across 40 states and Washington, D.C. provide coverage for at least one formulation of naloxone, the critical medication used to reverse opioid overdoses. However, barriers remain that could hinder patients' ability to obtain this life-saving drug.

In 2023, the U.S. Food and Drug Administration (FDA) made a significant move by approving naloxone, commonly known by the brand name Narcan, for over-the-counter sale. This decision was widely celebrated as a public health milestone aimed at improving access to naloxone. Nonetheless, the price, averaging $45 for a two-dose box, can be prohibitive for some individuals, particularly those in low-income brackets who are most affected by opioid overdoses.

The study conducted by Boston University School of Public Health (BUSPH) highlights the coverage landscape of naloxone within Medicaid managed care plans. As Medicaid covers a substantial portion of the U.S. population--over 70 million individuals--accessible naloxone is crucial for those at heightened risk of overdose.

The findings, published in JAMA Network Open, reveal that nearly all Medicaid managed care plans include at least one of the naloxone formulations. Importantly, around 80% of Medicaid beneficiaries are enrolled in these plans, making the coverage of naloxone vital for reducing overdose fatalities.

According to Sage Feltus, the lead researcher, the affordability of naloxone is a major concern. Given that Medicaid recipients experience overdose death rates that are significantly higher than the general population, making naloxone available without excessive costs is essential to saving lives. The study underscores the need for low-barrier access to naloxone to ensure that high-risk individuals can obtain this medication.

The research team included experts from various institutions, including Dr. Maureen Stewart from BUSPH and Dr. Jeffrey Bratberg from The University of Rhode Island. The study comes in the context of a concerning rise in opioid overdose deaths, which peaked during the COVID-19 pandemic but have since shown signs of decline, according to provisional data from the Centers for Disease Control and Prevention (CDC).

Naloxone is recognized as a cornerstone in addressing the opioid crisis, as it can swiftly counteract the effects of opioid overdose from substances such as heroin and fentanyl. Experts have long advocated for increased awareness and accessibility of naloxone to effectively mitigate overdose-related fatalities.

As part of the study, researchers analyzed preferred drug lists from 264 Medicaid managed care plans, representing 65.3 million Medicaid recipients. These lists dictate how insurance companies negotiate drug prices with manufacturers. In their analysis, the team assessed the coverage of various naloxone formulations, which include both brand-name and generic options.

While the majority of plans reported covering at least one formulation of naloxone, including 94% covering generic injectables or 4-mg nasal sprays, the existence of quantity limits and other restrictions varied by plan. For instance, over half of the plans had state-defined preferred drug lists, which were less likely to include coverage for generic injectable naloxone.

Notably, certain states with high rates of opioid overdose, such as Ohio, Kentucky, and Tennessee, had no managed care plans covering naloxone at all. This raises questions about how coverage policies correlate with overdose rates and highlights the need for further investigation.

Plans in states with lower overdose rates tended to cover more naloxone formulations and were less inclined to impose quantity limits. The findings suggest a need for additional research to explore the impact of Medicaid coverage on health outcomes and the necessity for managed care plans to reduce restrictive policies that limit access to naloxone.

To enhance access, states could mandate that managed care plans cover all naloxone formulations by establishing a uniform preferred drug list. This approach could simplify access, facilitating a more effective response to the ongoing opioid crisis.