Will Availability of Over-the-Counter Narcan Increase Access?

The availability of naloxone, commonly known as Narcan, as an over-the-counter (OTC) medication has the potential to widen access to this life-saving medication that can reverse opioid overdoses. However, several barriers could hinder its widespread uptake and access, such as pharmacy stocking decisions, cost, lack of awareness about accessing the drug in pharmacies, and confusing insurer reimbursement policies. At present, two versions of OTC Narcan have been approved by the FDA, but only one is currently available in pharmacies. Even if stores decide to stock OTC Narcan, its price tag, roughly $45 for a 2-dose, 4mg nasal spray may present a cost barrier for many, including friends and family who wish to carry the drug as a precaution. The urgency to address this issue is underscored by recent data: opioid overdoses in 2022 slightly increased to 81,051, surpassing 2021’s 80,411 and marked a striking 63% increase from 2019 (49,860), the year before the pandemic struck. A recent KFF poll revealed that 29% of adults say either they or a family member have grappled with opioid addiction.

This policy watch looks at state policies and research related to prescription Narcan and some of the challenges related to the access, availability, and affordability of OTC Narcan. Although ‘Narcan’ is a brand name for an opioid overdose reversal drug containing naloxone, many people use the term to refer to similar opioid overdose reversal medications. For clarity and simplicity, we use ‘Narcan’ in this brief to refer to medications containing naloxone whose purpose is to reverse an opioid overdose.

Where will OTC Narcan be available?

While pharmacies and other retailers have the option to stock OTC Narcan, not all will carry it. Settings like convenience and grocery stores are also permitted to sell it, but it is uncertain how many will actually have it on their shelves.

Pharmacy ownership, rurality and area overdose rates may influence pharmacy decisions to stock Narcan. How pharmacies stock prescription Narcan may provide some insights into how widely available OTC Narcan will be. In a 2022 study that included pharmacies in 11 states, approximately 30% of pharmacies did not stock prescription Narcan nasal spray. The study identified that independent pharmacies, those in rural areas, and pharmacies in states with lower overdose rates or without expanded Medicaid were less likely to have it available. Since Medicaid covers a substantial share of people with opioid use disorder and ensures coverage for prescription Narcan in all states, pharmacies in states with higher Medicaid enrollment, such as those that expanded Medicaid, may be more likely to stock prescription Narcan.

State legislation related to standing orders and legal immunity may also play a role in shaping the availability of Narcan at pharmacies. A report by the Legislative Analysis and Public Policy Association showed that as of July 2022, all 50 states and D.C. had ways for people to access prescription Narcan without a traditional prescription, prior to the availability of OTC Narcan: in three states, pharmacists can write the prescription directly or dispense it without a specific prescription or standing order; in 33 states, statewide “standing orders” allow pharmacists to dispense prescription Narcan, and in the remaining 14 states and D.C., pharmacists and doctors can agree to create their own standing orders, though the frequency of such arrangements remains uncertain. Statewide standing orders authorize pharmacists to dispense prescription Narcan using a general prescription as authorization, typically signed by a physician within a state agency, instead of individual prescriptions. Even in the presence of statewide standing orders, some pharmacies still abstain from dispensing prescription Narcan. Variability in laws, public or pharmacy staff awareness, ease of access, and costs may have all impacted prescription Narcan’s actual accessibility. Furthermore, differences in legal protections for individuals administering Narcan during emergencies could influence both supply and demand. In states lacking such protections, potential buyers of OTC Narcan might be deterred by concerns over personal liability. This apprehension could, in turn, influence retailers’ decisions to stock the medication.

Even if available in pharmacies, where the product is displayed can affect access.  The way OTC Narcan is displayed in stores and the purchase process may be an important element, as they can substantially influence a potential buyer’s comfort level.

How will the cost of OTC Narcan affect access?

For people paying out of pocket, the cost of OTC Narcan at $45 may present a substantial hurdle. This may be especially true for friends and families wanting to keep Narcan on hand for emergencies. Opioid use disorder is more prevalent among people who are lower income, which may make the additional $45 for OTC Narcan out of reach. Additionally, potent opioid overdoses might require multiple Narcan doses, increasing the overall expense.

Some health departments and harm reduction organizations might offer OTC Narcan for free through methods like vending machines, online ordering, or direct distribution. To promote easy access, certain localities and organizations have begun distributing Narcan for free using low-barrier methods like vending machines or online systems. Although there’s potential for broader OTC Narcan accessibility through these methods, the degree of availability will vary by region and it isn’t clear how many organizations will adopt this easy-access approach. Before OTC Narcan’s arrival, obtaining free or reduced access to prescription Narcan could be unclear, confusing to navigate, and could sometimes require extra steps or training.

Will insurance cover OTC Narcan?

Insurer coverage of OTC Narcan, requirements for a prescription, and out-of-pocket costs will vary by state and health plan.

Medicaid coverage of OTC Narcan will vary across states, and it is uncertain how much access will increase relative to prescription Narcan. Medicaid generally isn’t mandated to cover OTC drugs, but 42 states chose to cover certain OTC drugs as of 2018. For Medicaid enrollees to access covered OTC drugs, two conditions must be met: they need a prescription, and the drug must be on the state’s OTC drug formulary (states and/or MCOs may need to update their formularies). To help increase access to OTC drugs, some states may use standing orders that enable pharmacists to dispense certain drugs without requiring individuals to get a prescription from a separate clinician. This approach was adopted in some states for access to COVID tests and may be used by states to expand access to Opill, the first OTC daily oral contraceptive pill. States may also be able to gain approval to cover broad therapeutic categories of OTC to limit approval for specific drugs. For Medicaid FFS and managed care plans that do cover OTC Narcan, Medicaid enrollees will have minimal to no copay costs.

Private insurance coverage for OTC Narcan is also likely to vary across insurers and states. Some private insurers may require a prescription as well as coverage for OTC Narcan on their OTC formularies. Relative to Medicaid, individuals with private insurance may have higher copays for OTC Narcan if they choose to use insurance. The average copay for prescription Narcan in 2018 was about $35, only $10 less than the suggested retail price for OTC Narcan. In addition, some individuals with private insurance may have to initially pay out-of-pocket for the drug and then submit a reimbursement claim, as was the case during the public health emergency with COVID tests for some insurers. However, unlike with COVID tests, there is no overarching federal mandate for private insurers to cover OTC Narcan. At least one private insurer has pledged to cover OTC Narcan in full, and it is possible that others might do the same.

Lack of awareness and confusion about insurance coverage may be barriers to access OTC Narcan. If people are unaware that insurance might cover OTC Narcan costs or that standing orders exist, they might avoid purchasing Narcan at all to avoid out-of-pocket expenses. Additionally, it is uncertain how insurance covers OTC Narcan for someone other than the policyholder who uses opioids.

What to watch

Making Narcan available OTC has the potential to expand access, but several obstacles may limit its reach. Policy decisions by state Medicaid programs and insurers to cover OTC Narcan, decisions by pharmacies on whether to stock OTC Narcan, the product’s placement within stores, and lingering stigmas can impact accessibility. Furthermore, public knowledge plays a role; many people may not realize that OTC Narcan is available without a prescription from a doctor and that insurance may help cover the costs. These challenges are not confined to OTC Narcan; other prescription drugs, which have recently gained approval for sale OTC may face similar hurdles.

Local or state governments may improve accessibility through outreach and educational campaigns. Initiatives like Narcan vending machines, immunity laws for Narcan administrators, and Narcan availability in schools or general settings may also boost access. Approving OTC Narcan is one of many steps that have been taken to address the opioid crisis, and this approach is in line with the Substance Abuse and Mental Health Services Administration’s strategic plan. It is likely that these policies and efforts to combat the opioid epidemic will continue to evolve as other factors and emerging illicit drugs, like xylazine and nitazene, intersect with the opioid epidemic.