Policy Solutions


Eliminate Fail First Policies

Fail first policies, also known as step therapy, are procedures imposed by some health insurance companies that require patients to try and “fail” the insurer's preferred medications before they can access the medicine originally prescribed by their provider.

Providers must obtain approval from insurers, or demonstrate that current medications are showing unsuccessful results, before they can be permitted to prescribe their recommended medications. In some cases, patients are required to try and fail numerous alternative medications and/or take medications they have previously tried without success.

While these policies are intended to control and minimize health costs by having patients start with the most co-effective medical option, they create significant barriers to life-saving treatment, undermine providers’ clinical judgment, and give the insurance company the final say on whether or not they will cover a medical request. They also are time-consuming and create delays in accessing medications that providers deem best suited for the patient.

Fail first policies greatly impede access to substance use disorder (SUD) medications and treatments. Removing barriers to accessing medications for addiction treatment (MAT) is crucial, given the research that demonstrates its effectiveness in treating SUDs. These policies restrict patient access and create a significant disincentive for physicians to provide their patients with treatment options that may play a role in addressing the opioid crisis.

The Details

  • As of January 1, 2021, 29 states have passed laws to protect patients from the adverse consequences of fail first policies.1
  • A majority of state legislatures have now enacted legislation designed to limit health plans’ ability to employ step therapy
  • Only seven states have laws that include protections for Medicaid beneficiaries
  • Treatment is not a one-size-fits-all and must be tailored to a patient's individualized needs.


Implement Co-prescribing of Naloxone with Opioid Prescriptions

For more than 40 years, naloxone has been used to reverse the effects of opioid overdose. Despite the overwhelming research that naloxone significantly reduces overdose fatalities, access to the medication remains challenging.

There are well over 142 million annual opioid prescriptions dispensed in the U.S., but for every 100 high-dose of opioid prescriptions, there are only about two naloxone prescriptions dispensed.2-3 Co-prescribing naloxone, a practice when a medical professional prescribe naloxone in conjunction with a prescription opioid, has been found to reduce emergency department visits by approximately 63% after one year, and patients often find the offer of a naloxone prescription acceptable, as do primary care providers.4 Making naloxone available through pharmacies without a prescription (known as a standing order) has shown to increase access to life-saving medication and has contributed to lower overdose deaths.

Preliminary evidence indicates that co-prescribing naloxone to patients taking high doses of prescription opioids for chronic pain is associated with fewer visits to emergency rooms and that when naloxone is prescribed with opioids, the overdose risk is decreased even if the naloxone prescription isn’t filled. In 2016, the Centers for Disease Control and Prevention (CDC) first recommended co-prescription of naloxone with opioids, and by 2019, a study of Medicare Part D patients indicated that co-prescription had increased.5-8 The National Institute on Drug Abuse (NIDA) advises healthcare workers to monitor patients receiving long-term opioid therapy for the symptoms of an opioid use disorder (OUD), including “loss of control, craving and preoccupation with use, and use despite negative consequences."9

The Details

  • Naloxone is not a controlled substance and can be prescribed by any licensed healthcare provider.
  • According to a large national study, states with naloxone access laws had a 14% lower incidence of opioid-overdose deaths compared to states without naloxone access laws.10
  • Co-prescribing naloxone with an opioid prescription is not a federal requirement, but it is strongly recommended by federal agencies. In 2018, the Department of Health and Human Services (HHS) issued federal guidelines that recommend healthcare providers co-prescribe naloxone with opioid medications to patients that are not prescribed opioids that use illegal substances or are at high risk of engaging in risky behavior.7
  • As of 2017, all 50 states and DC have enacted laws to improve access to naloxone. However, the authority and protections vary state by state. Nine (9) states require co-prescribing naloxone in certain situations such as a certain dose of opioid, concurrent benzodiazepine use, and/or patient history of opioid use disorder or overdose.11

Model State Law


Co-prescribing laws have also been enacted by several states over the past several years. California for example, passed Assembly Bill (AB) 2760 in 2018, which requires medical providers to offer naloxone to patients that are receiving a high-dose opioid, are concurrently prescribed benzodiazepines, and if patients are at high risk of overdose or have a history with SUD. A year later, the state legislature passed AB 714, which specifies the requirements for offering naloxone with benzodiazepine medications.


Remove Fentanyl Test Strips from Drug Paraphernalia Laws

Synthetic opioids, such as fentanyl, accounted for around 56,000 deaths in 2020, a 56% increase from 2019 and contributing to over 82% of all opioid-related deaths in 2020.14

Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin, and can be easily mixed into other drugs.15 Given the potency and increasing prevalence of fentanyl, policies must be adopted to help protect individuals with SUD from detecting this deadly drug. Increasing the access and distribution of equipment to test drugs, such as fentanyl test strips, are among several emerging harm reduction policies to reduce overdose risk and death.

of all opioid-related deaths in 2020 involved synthetic opioids, such as fentanyl

Fentanyl test strips save lives by enabling people to detect the presence of fentanyl in other drugs, whether it be pills, powers, or injectables. However, many states prohibit the possession and/or sale of fentanyl test strips under state-level drug paraphernalia laws. While these laws are intended to discourage illicit drug use, they instead create barriers to essential tools to reduce the risk of overdose and avoidable death.

Laws surrounding fentanyl test strips and/or testing equipment vary state-by-state. Some states have amended their laws to exclude fentanyl test strips and/or testing equipment from its definition of drug paraphernalia, but most states do not specifically reference fentanyl test strips. Other states, where testing equipment is illegal, have announced that they will not prosecute and/or arrest people for possessing the equipment.

The Details

  • A 2019 study that investigated the correlation between fentanyl test strips and substance use behaviors among people who inject drugs found that 43% of individuals that utilized fentanyl test strips reported a change in their substance use behaviors, such as using less, and 77% reported that fentanyl test strips made them feel better able to protect themselves from an overdose.16
  • Forty-nine (49) states and the District of Columbia have one or more criminal laws around drug paraphernalia. Alaska is the only state that does not have criminal laws pertaining to drug paraphernalia.17
  • Twenty-five (25) states and DC have legalized the use and/or possession of fentanyl test strips and/or testing equipment by either removing testing equipment from the drug paraphernalia definition or not including it in the definition in several years.17 Only 7 of those 25 jurisdictions limit testing equipment to fentanyl test strips.17 Of the 25 states where testing equipment is illegal, 12 states will not arrest or prosecute individuals for using and/or possessing testing equipment under particular circumstances, such as situations where Good Samaritan laws apply. As of April 2022, legislation to legalize fentanyl test strips and/or testing equipment has been introduced in 11 of the 25 states where testing equipment is currently illegal.
  • In some states, where testing equipment is included in its definition of drug paraphernalia, harm reduction organizations and other programs are allowed to distribute fentanyl test strips and other testing equipment.18


Eliminate Prior Authorization

Prior authorization insurance requirements create significant barriers for SUD patients by delaying treatment initiation and restricting access to care at critical moments.

Prior authorization is a process by which health care providers must obtain advance approval from some health insurance companies before prescribing certain procedures, treatments, medications, or services to determine if they will be covered by a patient’s health plan. The process is intended for insurers to minimize costs, limit risks, and oversee coverage decisions. This process can also facilitate discriminatory practices, which are illegal under federal law.

of physicians report that prior authorization delayed access to necessary care for patients

Addiction is a disease of the brain that can make it difficult to become and stay motivated to enter treatment. Delaying treatment or restricting access to care can lead to missed opportunities and serious consequences, resulting in patients failing to return for follow-up appointments, continued or recurrence of substance use, overdose, and death.19 It is critical that states adopt policies that remove prior authorization requirements in order to increase access to evidence-based SUD treatments and affordable care and reduce avoidable health consequences and deaths from addiction.

The Details

  • A 2021 study by the American Medical Association found that 93% of physicians reported that prior authorization delayed access to necessary care for patients, 82% reported that prior authorization can sometimes lead to patients abandoning treatment, 91% reported that prior authorization can negatively impact patient outcomes, and 88% of physicians describe prior authorization as a high or extremely high burden.20 The study also found that physicians spend nearly two business days completing an average of 41 prior authorizations each week.
  • As of April 2020, 21 states and the District of Columbia have enacted laws that remove prior authorization requirements for SUD medications or services in public and/or private health insurance plans (Arizona, Arkansas, Colorado, Delaware, Illinois, Iowa, Maine, Maryland, Massachusetts, Missouri, Montana, New Hampshire, New Jersey, New York, Oregon, Texas, Vermont, Virginia, Washington, West Virginia, and Wisconsin).21 Only four (4) states have laws that remove prior authorization for SUD medications and services in both public and private plans (Delaware, Illinois, Maine, and Washington).
  • As of July 2021, 43 states used Section 1135 Waivers to suspend prior authorization in Medicaid fee-for-service plans to increase access to SUD treatment during the COVID-19 public health emergency, and two (2) states permanently removed prior authorization requirements for MOUD (Iowa and New York).22

Model State Law

New York

New York has taken great strides to remove barriers that delay or restrict access to SUD treatment and services by eliminating prior authorization requirements from both public and private/commercial insurance companies. Most recently, on December 23, 2021, New York enacted legislation (S.649A/A.2030) that allows Medicaid beneficiaries to access whichever FDA-approved medications for opioid use disorder (MOUD) are most beneficial to them and removes all mandated prior authorization, utilization control, or lifetime limit requirements. Previously, Medicaid beneficiaries could not access all MOUDs and may have been limited to a specific medication.