NY Mandates Health Insurance Coverage for Naloxone

On Sept. 28, 2017, the New York (NY) Department of Financial Services published Circular Letter No. 16 (2017). The letter relates to health insurance coverage for naloxone. Previously, NY published Circular Letter No. 6 (2016), which makes coverage for naloxone mandatory when medically necessary.

According to the federal Substance Abuse and Mental Health Services Administration’s website, naloxone is an FDA-approved prescription drug used to block or prevent the effects of opiates and opioids, such as oxycodone. Naloxone is often used in emergency situations to prevent or reverse the effects of an opioid overdose.

Based on federal and state law, DFS takes the position that carriers must provide coverage for naloxone on an outpatient basis when prescribed to an individual by an authorized provider, as they would for any other prescribed drug. In addition, naloxone must also be covered on an inpatient basis when medically necessary. Furthermore, carriers may not impose any arbitrary limits on coverage for naloxone. As an example, carriers may not place an annual limit on coverage for an unused naloxone prescription refill, unless medically warranted. In addition, when determining the appropriate dosage for naloxone coverage, carriers should consider that there have been cases of overdoses that involve fentanyl and that have required two or more doses of naloxone to reverse the effects of the fentanyl overdose.

While the letter contains no new employer compliance obligations, employers should be aware of the coverage requirements relating to naloxone. Such awareness will help address any employee questions that may arise relating to opioid addiction and coverage of naloxone.

Circular Letter No. 16 (2017) »