No-cost coverage of preventive opioid overdose reversal drugs

(a)

Coverage under Medicare

(1)

Coverage

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (A)in subparagraph (JJ), by adding and after the semicolon at the end; and (B)by adding at the end the following new subparagraph:

(KK)a preventive opioid overdose reversal drug (as defined in subsection (nnn)) furnished on or after January 1, 2026;

(2)

Preventive opioid overdose reversal drug defined

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(nnn)

Preventive opioid overdose reversal drug

The term preventive opioid overdose reversal drug means an opioid overdose reversal drug, which may be either intranasal or intramuscular, that is furnished by a physician, nurse practitioner, physician assistant, or other attending clinical personnel (as determined by the Secretary by regulation) to an individual who is an inpatient of a hospital, critical access hospital, or rural emergency hospital, or is a patient of the emergency department of such a hospital or an ambulatory surgical center, but only if— (1)such physician, nurse practitioner, physician assistant, or attending clinical professional determines that such individual is at risk for an opioid overdose; and (2)such drug is furnished at the time such individual is discharged from the hospital or leaves the emergency department or ambulatory surgical center, as the case may be, together with instructions for the administration of such drug.

(3)

Prohibition of cost sharing

Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended— (A)in subsection (a)(1)— (i)in subparagraph (S)(i), by striking subparagraph (EE), and inserting subparagraphs (EE) and (II),; (ii)in subparagraph (GG), by striking and at the end; and (iii)by inserting , and (II) with respect to a preventive opioid overdose reversal drug (as defined in section 1861(nnn)) furnished on or after January 1, 2026, the amounts paid shall be 100 percent of the lesser of the actual charges for such drug or the amount determined under section 1842(o) before the semicolon at the end; and (B)in subsection (b)— (i)by striking , and (13) and inserting (13); and (ii)by striking section 1861(n).. and inserting section 1861(n), and (14) such deductible shall not apply with respect to a preventive opioid reversal drug (as defined in section 1861(nnn)) furnished on or after January 1, 2026.. (4)

Prohibition of cost sharing for Medicare Advantage plans

Section 1852(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended— (A)in clause (iv)— (i)by redesignating subclause (VIII) as subclause (IX); and (ii)by inserting after subclause (VII) the following new subclause:

(VIII)A preventive opioid reversal drug (as defined in section 1861(nnn)).

; and

(B)in clause (v), by striking and (VI) and inserting (VI), and (VIII). (b)

Coverage under Medicaid

(1)

Mandatory coverage

(A)

In general

Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by striking and (30) and inserting (30), and (32). (B)

Alternative benefit plans

Section 1937(b) of the Social Security Act (42 U.S.C. 1396u–7(b)) is amended by adding at the end the following new paragraph:

(9)

Preventive opioid overdose reversal drugs

Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless, beginning on January 1, 2026, such coverage includes (and does not impose any deduction, cost sharing, or similar charge for) preventive opioid overdose reversal drugs described in section 1861(nnn).

(2)

Inclusion in medical assistance

(A)

In general

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended— (i)in paragraph (31), by striking and at the end; (ii)by redesignating paragraph (32) as paragraph (33); and (iii)by inserting after paragraph (31) the following new paragraph:

(32)beginning January 1, 2026, preventive opioid overdose reversal drugs described in section 1861(nnn); and

(3)

Application of rebate requirements

Section 1927 of the Social Security Act (42 U.S.C. 1396r–8) is amended— (A)in subsection (d)(7), by adding at the end the following new subparagraph:

(F)Preventive opioid overdose reversal drugs described in section 1861(nnn) that are furnished as medical assistance in accordance with section 1905(a)(32) and section 1902(a)(10)(A).

; and

(B)in subsection (k)(4)— (i)by striking If a State plan and inserting:

(A)

In general

If a State plan

; and

(ii)by adding at the end the following new subparagraph:

(B)

Preventive opioid overdose reversal drugs

Beginning January 1, 2026, in applying paragraph (2)(A) to a preventive opioid overdose reversal drug described in section 1861(nnn), such drug shall be deemed a prescribed drug for purposes of section 1905(a)(12).

(4)

Prohibition of cost sharing

(A)

In general

Section 1916 of the Social Security Act (42 U.S.C. 1396o) is amended— (i)in subsection (a)(2)— (I)in subparagraph (I), by striking or at the end; (II)in subparagraph (J), by striking ; and at the end and inserting , or; and (III)by adding at the end the following new subparagraph:

(K)beginning January 1, 2026, preventive opioid overdose reversal drugs described in section 1861(nnn); and

; and

(ii)in subsection (b)(2)— (I)in subparagraph (I), by striking or at the end; (II)in subparagraph (J), by striking ; and at the end and inserting , or; and (III)by adding at the end the following new subparagraph:

(K)beginning January 1, 2026, preventive opioid overdose reversal drugs described in section 1861(nnn); and

(B)

Application to alternative cost sharing

Section 1916A(b)(3)(B) of the Social Security Act (42 U.S.C. 1396o–1(b)(3)(B)) is amended by adding at the end the following new clause:

(xv)Beginning January 1, 2026, preventive opioid overdose reversal drugs described in section 1861(nnn).

(c)

Coverage under TRICARE

Section 1074g of title 10, United States Code, is amended as follows: (1)In subsection (a)(6), by adding at the end the following new subparagraph:

(F)Notwithstanding subparagraphs (A), (B), and (C), beginning on January 1, 2026, an eligible covered beneficiary shall not be required to pay a cost-sharing amount for a preventive opioid overdose reversal drug.

(2)In subsection (i), by adding at the end the following new paragraph:

(5)The term preventive opioid overdose reversal drug has the meaning given such term in section 1861 of the Social Security Act (42 U.S.C. 1395x).

(d)

Regulatory guidance

(1)

State boards

Not later than 1 year after the date of the enactment of this Act, the Commissioner of Food and Drugs shall issue guidance for State boards of pharmacy, nursing, and medicine with respect to— (A)enhancing safe and effective hospital-based dispensing and distribution of opioid overdose reversal drugs; and (B)eliminating barriers to such dispensing and distribution. (2)

Hospital

Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall issue guidance for hospitals with respect to billing for preventive opioid overdose reversal drugs described in section 1861(nnn) of the Social Security Act, as added by subsection (a)(2). (e)

Rule of construction

Nothing in this section shall be construed to require a provider of services or supplier to furnish a preventive opioid overdose reversal drug described in section 1861(nnn) of the Social Security Act, as added by subsection (a)(2), to an individual at risk of an opioid overdose.