Narcan in Workers’ Compensation Medicare Set-Asides

5.20.2022 Blog

Narcan, an opioid antagonist, works by blocking the effects of opioid drugs on the central nervous system. Narcan and its generic, Naloxone, are administered to patients experiencing opioid overdose. First developed in the early 1960’s, Naloxone has been vital more recently in the battle against the opiate crisis. With the rise in opioid prescription pain medication use, opioid drug abuse, addiction, and overdoses increased. Therefore, the need and use for Naloxone rose too.

Opioid Use By Medicare Beneficiaries: Not surprisingly, prescription opioid use for chronic pain among workers’ compensation claimants including those who are current Medicare beneficiaries skyrocketed, with risks for abuse following. The danger of misuse or even accidental overdose prompted insurers including Medicare to cover Narcan/Naloxone. Most Part D plan formularies now include Naloxone.

Initially, Narcan was developed for intravenous administration or intramuscular injection. The FDA approved the user-friendly nasal spray formulation in 2015. Soon thereafter, in 2016, Narcan started being included in Medicare Set-Asides where opioid drugs were projected. Early pricing was substantial due to the approximately $2,000 brand cost per dose. However, approval of the first generic nasal spray in 2019 significantly reduced costs and increased access and prescription rates. Generic Naloxone soon reached the MSA marketplace at a stable cost of $78 per dose. It is now well-accepted for generic Naloxone to be allocated.

Concerning Developments: CMS oddly has allocated Naloxone where it has not been specifically prescribed,  previously utilized, recommended for future use, or even mentioned by a treating physician. And CMS will project use of the medication over a claimant’s entire life expectancy. More concerning are recent MSAs allocating for Naloxone for claimants using non-opioid medications such as Gabapentin and Cyclobenzaprine. Such projections appear to be blatant error as Naloxone would not counteract these medications even when taken in excess.

The drug itself also continues to evolve with the introduction in the fall of 2021 of a double-dose nasal spray which is priced the same as the lower dose formulation. Development of over-the-counter products are also having an impact. Eventually, if it becomes readily available over-the-counter, Naloxone might be excluded from MSAs.

The Future for Naloxone and MSAs: The nationwide response to the opioid crisis has fortunately resulted in fewer prescriptions for opiates, including among workers’ compensation claimants and Medicare beneficiaries. This phenomenon has trickled down to MSAs. Decreased opioid prescriptions and increased availability of Naloxone at a lesser cost are a positive trend and outcome. At NBKL, our workers’ compensation defense and Medicare Secondary Payer attorneys provide strategies to address use of opioids among workers’ compensation claimants. Contact our team of Medicare Secondary Payer attorneys with any problematic claims involving prolonged opioid use.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.