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Federal Register / Vol. 86, No. 179 / Monday, September 20, 2021 / Rules and Regulations opioid crisis in our veteran community.
The commenter suggested that adding a clear definition of who VA considers high risk is also an essential step in ensuring that any veteran needing these measures will have the availability of lifesaving opioid antagonists afforded to them. A commenter stated that the opioid crisis in the United State is getting worse every day and it is VAs duty to eliminate copays for opioid antagonists and education on use of opioid antagonists. Another commenter stated that high-risk veterans should have adequate access to opioid antagonists and that veterans should also have access to counseling and educational information on the subject of opioid addiction.
A commenter stated that eliminating the copayment for opioid antagonists and the education on the use of opioid antagonists will relieve a veteran of those financial burdens while receiving treatment. The commenter added that veterans have sacrificed enough to protect the people of this country and it is our responsibility to provide proper health care and encourage healthy living. Eliminating the copayment will allow veterans to fight this battle with focus and determination and removing a stressor such as a copayment can increase the chances of a successful recovery.
A commenter was in favor of the rule and added that VA has several programs in place to help veterans manage pain that do not include the use of opioids.
This same commenter stated that the use of naloxone rescue treatments is an option for opioid risk mitigation and that proper education on naloxone should be given with frequent observation of the veteran and documentation in the veterans medical records. This commenter also stated that eliminating the copayment will allow a veteran to fight this battle with focus and determination. Treatment timeframe varies per situation, but when trying to heal the mind and body simultaneously, removing a stressor can increase the chances of a successful recovery.
Another commenter was in support of the proposed rule and stated that the rule will be impactful to veterans battling opioid use disorder. Several commenters stated that by waiving the requirement to pay a copayment to receive opioid antagonists or education on their use for qualifying veterans, VA
is recognizing that costs can pose a barrier for veterans to health care accessibility and it is taking the right steps to alleviate those barriers. A
commenter added that this rule is a statement by VA of support of their at-

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risk patients and that it places the values of their patients lives over the cost of this drug. Another commenter similarly stated that removing copayment requirements for veterans will likely result in increased access to these potentially life-saving medications. The commenter praised VAs efforts and believes that this rule will help reduce the incidence of overdose deaths among the veteran population.
A commenter stated that the proposed rule was a fine example of an executive agency ensuring compliance with Congressional direction.
VA thanks the commenters for their support of the rule. We are not making any changes based on these comments.
Comment on use of term opioid antagonist.
One commenter was in support of the rule but stated that VA should change the wording in the proposed rule from antagonist to something that is more relatable and not so demeaning to people who will interpret it the wrong way.
VA notes that the utilization of the term antagonist in the proposed rule is the correct medical term to describe the specific class of medications being authorized for provision to at risk veterans. An antagonist is a chemical that acts within the body to reduce the physiological activity of another chemical substance such as an opioid.
Since the term specifically describes this class of medication, VA is not making changes based on this comment.
Comments on education on opioid antagonists.
A commenter was in general support of the rule but indicated that the copayment for the outpatient visit should be eliminated regardless of whether the veterans medical visit is solely for education on the use of opioid antagonists or the education is provided in conjunction with other types of care.
Under 38 United States Code U.S.C.
1710 and 38 CFR 17.108c VA is required to charge copayments for outpatient and inpatient health care services when certain criteria are met.
VA clarifies, in 38 CFR 17.108c2, a veteran will only be charged one copayment per day even if there are multiple encounters. In accordance with section 1710g3B of title 38, United States Code, VA is exempting from the copayment requirement those outpatient health care visits whose sole purpose is to provide education on the use of an opioid antagonist. However, when the outpatient visit provides health care services in addition to the education on an opioid antagonist, VA must assess the veterans copayment for the
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additional services in accordance with 38 U.S.C. 1710. VA emphasizes that the veteran will not be charged a separate copayment for the education but will be assessed one copayment for the entire encounter. VA notes this results in the same outcome as the veteran would have experienced if the veteran had not received education on the use of an opioid antagonist. VA is not making any changes based on this comment.
Comments on definition of at high risk veterans.
Several commenters were generally in support of the rule but were concerned that the rule only focused on veterans who VA classified as high risk. The commenters stated that all veterans, not just those with a diagnosed risk of opioid overdose, should be eligible for the waived copayment. A commenter stated that if a veteran needs the opioid antagonist, then costs should not be a concern whether they are high risk or not. The commenter added that the fact the veteran is in need of the antagonist is sufficient evidence the veteran is at high risk. Also, the commenter stated that while the proposed rule would be an improvement and would lead to more lives being saved, more aggressive action to expand the target population to all veterans would be warranted and welcomed by the American people.
VA defined a high risk veteran in the proposed rule as a veteran who is prescribed or using opioids, or has an opioid use history, and who is at increased risk for opioid overdose as determined by VA. VA also stated that, in the alternative, a high risk veteran is one whose provider deems, based on their clinical judgment, that the veteran may benefit from ready availability of an opioid antagonist. VA believes this definition is broad enough to allow health care professionals the discretion to provide opioid antagonists and related education to any veteran who needs it without charging a copayment.
In addition, VA has programs in place to assist veterans who are suffering financial hardship or who would face difficulties in making copayments; these efforts include measures to identify barriers for veterans at high risk due to substance use and to review the veterans financial barriers and provide assistance as needed. VA is not making any changes based on this comment.
Another commenter stated that the proposed rule assumes that all those who are considered high risk would be appropriately identified to meet the requirements for the copayment waiver.
The commenter added that this approach runs the risk of missing vulnerable individuals who may not fall within the parameters outlined by VA

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