Report: Despite expanded access to naloxone through Medicaid, few getting overdose drug


A new report from the Office of the Inspector General of the U.S. Department of Health and Human Services had found that despite access to naloxone for Medicaid beneficiaries expanding, Medicaid pays for a significantly small percentage of America’s naloxone prescriptions.

The OIG said the Center for Medicaid and Medicare Services (CMS) paid for 21 times more doses of naloxone in 2018 than it did in 2014. Despite that growth, Medicaid paid for only 5 percent of the naloxone distributed in the United States.

That’s concerning, the OIG said, because Medicaid covers nearly 40 percent of nonelderly adults with opioid use disorder. And in some states with high opioid overdose mortality rates, Medicaid pays for relatively little naloxone.

The OIG looked at state-reported Medicaid data to see how naloxone utilization changed in the program between 2014 and 2018. Using manufacturer-reported sales data, the office was about to determine how much naloxone was distributed in the United States and what proportion of it was paid for by Medicaid for each year. The office also used data on Medicaid drug spending to look at how statutory rebates from manufacturers to states affected Medicaid payments for naloxone during that period.

According to the report, CMS has taken steps to increase access to naloxone. All state Medicaid agencies in the United States have removed the requirement for prior-authorization for naloxone prescriptions. Some have allowed friends and family of patients with opioid use disorder who are enrolled in Medicaid to obtain naloxone on their behalf.

In January 2016, the OIG said, CMS encouraged states to increase access to the drug by placing it on the preferred drug list. As of 2018, 43 states had done so. Additionally, CMS recommended that states implement rules that would identify Medicaid beneficiaries who might be at high risk of an opioid overdose and be considered a candidate for naloxone co-prescribing or co-dispensing.

The OIG found that in 2018, Medicaid paid for more than 477,000 doses of naloxone nationwide, up from 23,000 doses in 2014. The office attributed that rise to the introduction of Narcan – a nasal spray version of the opioid-overdose reversal medication – that shifted naloxone’s formulations from injections requiring professional training to community-use requiring little to no training to administer. By 2018, Narcan represented nearly 90 percent of the naloxone doses reimbursed under Medicaid.

But that represents a fraction of the total doses distributed by drug manufacturers. In 2018, manufacturers distributed 10.4 million doses of naloxone. Medicaid paid for just 4.6 percent of them.

The OIG pointed out, however, that while Medicaid did not pay for the drug, Medicaid beneficiaries had access to the drug, and those patients could have gotten the drug from other sources, like state and local programs.

The report also found that, on average, Medicaid paid for 639 naloxone doses per every 100,000 beneficiaries nationally. State averages, however, varied wildly from a low of 68 doses per 100,000 to a high of 2,861 doses per 100,000. And in some of those states with high opioid overdose rates, the number of doses per 100,000 was low.

In Delaware, where the opioid overdose rate in 2018 was 43.8 deaths per 100,000 residents, Medicaid only paid for 441 naloxone doses per 100,000 beneficiaries – 31 percent less than the national average, the office said. And in New Hampshire, where the drug overdose rate is 35.8 deaths per 100,000 residents, the state paid for just 306 doses of naloxone per 100,000 beneficiaries.

The OIG said that statutory rebates paid by the manufacturers to Medicaid make providing naloxone relatively inexpensive for CMS. In 2018, the inspector general found, Medicaid’s net cost for Narcan was less than the discounted price Narcan’s manufacturer offered to public health organizations.

Because of its findings, the OIG recommended that CMS and state Medicaid agencies should be working to increase the number of at-risk beneficiaries who get community-use versions of naloxone while looking for ways to further expand naloxone availability under Medicaid. Expanding access is even more critical during the COVID-19 pandemic, the office said, as states struggle with increases in overdose deaths.

The OIG said that CMS did not “explicitly concur” with the office’s recommendations, but stated that it is already pursuing multiple strategies to increase the number of at-risk beneficiaries who can get Medicaid.